Role of body mass index in outcomes of patients hospitalized with COVID-19 illness.

Background: Since the start of coronavirus disease 2019 (COVID-19) pandemic, several studies have linked obesity with severity of illness as well as mortality in patients with COVID-19. Outcomes of patients with overweight or obesity, who develop critical illness, have been studied extensively over the past decade where the studies have shown conflicting results. In this study, we aimed to assess the association between the body mass index (BMI) classes and outcomes among hospitalized patients with COVID-19. Methods: This was a retrospective chart review of all adults admitted to our hospital with COVID-19 illness between 1 March 2020 and 30 June 2020. Patients were divided into four groups based on their BMI range as follows: patients with underweight (BMI < 18.5 kg/m2), patients with normal weight (BMI 18.5-24.9 kg/m2), patients with overweight (BMI 25-29.9 kg/m2), and patients with obesity (BMI ≥ 30 kg/m2). Results: 1274 patients were admitted during the study period. There were 24 (1.9%) patients with underweight, 268 (21%) patients with normal weight, 445 (34.9%) patients with overweight, and 537 (42.2%) patients with obesity. Patients with obesity were younger (p < 0.001) and there were more females among patients with underweight and patients with obesity (54% and 48% respectively, p < 0.001). There were no differences in subgroup with regards to presence of hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, and dyslipidemia. In a multivariate logistic regression model, patients with overweight and patients with obesity had higher odds of requiring mechanical ventilation. BMI class was not associated with difference in survival time in a multivariate analysis. Conclusions: In our large single-center study of hospitalized patients with COVID-19, patients with overweight and obesity had higher need for mechanical ventilation but had similar mortality when compared to patients with normal weight and underweight.

Use of Monoclonal Antibodies Therapy for Treatment of Mild to Moderate COVID-19 in 4 Patients with Rheumatologic Disorders.

BACKGROUND The use of monoclonal antibodies therapy (MAT) in early mild to moderate Coronavirus disease 2019 (COVID-19) has gained importance in recent times. However, there is limited information on the safety and efficacy of MAT in treating COVID-19 in patients with underlying rheumatologic diseases. Patients with rheumatologic diseases are usually on long-term corticosteroids and immunosuppressive therapy, which increases their risk for progressing to more severe forms of COVID-19. We report a case series of 4 patients with rheumatologic diseases who were treated with MAT for COVID-19. MATERIAL AND METHODS A retrospective observational study was conducted in our institution on patients with underlying rheumatological disorders who received MAT as per the EUA protocol of the FDA. RESULTS Two of the 4 patients were on immunosuppresive therapy at the time of receiving MAT. They recovered from COVID-19 without any adverse outcomes. No flare of underlying rheumatologic disease was noted. CONCLUSIONS MAT was observed to be a safe and effective therapy in 4 patients with rheumatological illnesses and COVID-19 treated at our hospital.

Chronic hepatitis-C infection in COVID-19 patients is associated with in-hospital mortality.

BACKGROUND: There is little evidence about the association of pre-existing hepatitis C infection (HCV) with outcomes in patients with coronavirus disease 2019 (COVID-19). AIM: To assess the prevalence of history of HCV among patients with COVID-19 and to study the relationship of in-hospital mortality in relation with other predictors of poor outcomes in the presence or absence of COVID-19 induced acute liver injury. METHODS: In a retrospective single-center study design, 1193 patients with COVID-19 infection were studied. Patients were then classified into those with and without a history of HCV, 50 (4.1%) and 1157 (95.9%) respectively. RESULTS: Multivariate cox-regression models showed that age, HCV, D-Dimer, and ferritin were the only predictors of in-hospital mortality. Acute liver injury and fibrosis score (Fib-4 score) were not different between both groups. Multivariate cox-regression model for liver profile revealed that aspartate aminotransferase/ alanine aminotransferase ratio, Fib-4 score, and HCV were predictors of in-hospital mortality. After propensity score matching HCV was the only predictor of mortality in the multivariate cox-regression model. A model including HCV was found to add predictive value to clinical and laboratory parameters. CONCLUSION: In patients with COVID-19, history of HCV infection leads to an accentuated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virulence, irrespective of baseline comorbidities, admission laboratory variables, or COVID-19-induced liver injury, which may be related to extrahepatic effects of HCV leading to enhanced ACE-2/TMPRSS mechanisms of SARS-CoV-2 viral entry, baseline cytokine-mediated pro-inflammation, and endothelial dysfunction.

The Incidence and Mortality Impact of Gastrointestinal Bleeding in Hospitalized COVID-19 Patients.

BACKGROUND: Patients requiring hospitalization to critical care units are at a higher risk for gastrointestinal (GI) bleeding. Although severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection is predominantly a pulmonary disease, other serious manifestations including thromboembolic phenomenon are reported. Acute respiratory distress syndrome (ARDS) requiring mechanical ventilation, use of steroids and anticoagulation are all known to increase the risk of GI bleeding significantly. AIM: To study the incidence of GI bleeding and its impact on mortality in patients admitted with SARS-CoV-2. METHODS: We retrospectively reviewed all patients admitted with SARS-CoV-2 from February 1, 2020 to April 15, 2020. We collected data including demographics, comorbid conditions, laboratory parameters, steroid and anticoagulant use. Coffee ground emesis, hematemesis, melena and hematochezia were defined as GI bleeding. All-cause mortality was reviewed for all patients included in the study. The relationship between GI bleeding and mortality was studied using logistic regression. RESULTS: We had a total of 1206 patients hospitalized with SARS-CoV-2 infection with an all-cause mortality of 34% (n = 411). The overall incidence of GI bleeding was 3.1% (n = 37) with no significant difference between the patients who survived versus died during hospitalization (1.3% vs 1.5%, p = 0.77). Logistic regression analysis did not identify GI bleeding as an independent predictor of mortality. Therapeutic doses of anticoagulation were administered in 13.3% (n = 161) of patients, of which 6.8% (n = 11) developed GI bleeding. Patients were more likely to develop GI bleeding with use of therapeutic doses of anticoagulation (29.7% vs 12.8%, p = 0.003), steroids (37.8% vs 18.5%, p = 0.003) and mechanical ventilation (48.6% vs 30.4%, p = 0.018). CONCLUSION: Patients hospitalized with SARS-CoV-2 infection are at risk of gastrointestinal bleeding. Therapeutic doses of anticoagulation, mechanical ventilation and steroid use are significant risk factors for GI bleeding. However, GI bleeding did not significantly alter the mortality rates in SARS-CoV-2-infected patients.

Implementation and outcomes of monoclonal antibody infusion for COVID-19 in an inner-city safety net hospital: A South-Bronx experience.

BACKGROUND: Monoclonal antibody therapy (MAT) is recommended in mild to moderate Coronavirus disease 2019 (COVID-19) patients who are at risk of progressing to severe disease. Due to limited data on its outcomes and the logistic challenges in administering the drug, MAT has not been widely used in the United States (US) despite of emergency use authorization (EUA) approval by the Food and Drug Administration (FDA). AIM: We aim to study the outcomes of MAT in patients predominantly from ethnic minority groups and the challenges we experienced in implementing the infusion therapy protocol in an inner-city safety-net-hospital in the South Bronx. METHODS AND RESULTS: We conducted a retrospective observational study of 49 patients who were offered MAT as per EUA protocol of FDA. Patient who met the criteria for MAT and received therapy were included in treatment group (n = 38) and the remaining (n = 11) who declined treatment were included in the control group. A majority of patients (76%) in the study group reported symptomatic improvement, the day after infusion. There was statistically significant reduction in COVID-19 related hospitalizations (7.8 vs 54.5%, P = < 0.001) mortality (0 vs 18.1%, P value = 0.008) in the treatment group. CONCLUSION: MAT reduced both hospitalization and mortality in this predominantly Hispanic patient population with mild to moderate COVID-19 with high risk factors for disease progression.

BNT162b2 mRNA Vaccine Interference with Co-Administration of Tdap Vaccine.

BACKGROUND It is unknown if the efficacy of the coronavirus disease-19 (COVID-19) vaccine is affected by the co-administration of other vaccines. The Centers for Disease Control and Prevention (CDC) has shifted their recommendations recently, allowing for the co-administration of the currently available COVID-19 vaccines with other vaccines. This is based on the experience with non-COVID-19 vaccines, where the immunogenicity and adverse event profiles were generally similar when vaccines are administered simultaneously or alone. CASE REPORT We present a case of a 29-year-old Asian woman who received the first dose of BNT162b2 mRNA vaccine and the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine at around the same time. BNT162b2 mRNA vaccine and Tdap vaccine were administered into the deltoid region of the left arm and right arm, respectively. We then monitored for immunogenicity. We observed a delay in the development of SARS-CoV-2 Spike (S1) protein antibodies at around 8 weeks after the second dose. CONCLUSIONS Unless warranted, it is important to adhere to current CDC recommendations with regards to the co-administration of vaccines. Although the administration of Tdap with COVID-19 vaccine in our case caused delay in immunogenicity, it did not negate the ability of the BNT162B2 mRNA vaccine to elicit an adequate immune response. The reason for delay in immune response with co-administration of COVID-19 vaccines with other vaccines is unknown and further studies are needed.

Potential predictors of outcomes among hospitalized COVID-19 patients treated with convalescent plasma: a single-center study.

Background: The coronavirus disease 2019 pandemic is a major international public health crisis, which has led to over 3 million deaths as of April 2021. Several therapeutics have been tried for this deadly illness including antivirals, immunosuppressive agents and convalescent plasma (CP). In this study, we present our inner-city safety net hospital experience with CP therapy. Methods: This was a retrospective chart review of hospitalized patients with confirmed COVID-19 who were treated with CP. Results: A total of 60 patients received CP during the study period. The mean age for patients in this study was 58.95 years. The most common presenting symptoms were shortness of breath (85%) and cough (73%). Hypertension (65%) and diabetes mellitus (55%) were the most common comorbidities in our patients. In our multivariate regression analysis, male sex, nausea and loss of appetite at presentation were associated with improvement in oxygenation after CP. Total survival time, history of obstructive airway disease, home use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers were associated with decreased survival, whereas Hispanic ethnicity showed a trend towards lower survival after CP therapy. Conclusions: Our study highlights several important characteristics of inner-city safety net hospital patient population who might benefit from CP therapy.

Impact of Prediabetes and Type-2 Diabetes on Outcomes in Patients with COVID-19.

INTRODUCTION: The true impact of prediabetes and type-2 diabetes in patients with COVID-19 remains unknown, with studies thus far providing conflicting evidence. METHODS: This is a single-center retrospective observational study involving 843 hospitalized patients with SARS-CoV-2 infection. Primary outcomes, mortality, and mechanical ventilation use were compared among the three groups: control, prediabetes, and type-2 diabetes. Binomial regression analysis was used to determine predictors of mortality and mechanical ventilation requirement. RESULTS: Age was a significant predictor of mortality. On stratifying our patients based on their age, older patients aged 55 years and above had no difference in mortality or mechanical ventilation requirement among the three groups of control, prediabetes, and type-2 diabetes. However, among the younger population aged less than 55 years, patients with type-2 diabetes had significantly higher mortality as compared with patients in control and prediabetes groups (27% vs 12.5% vs 9%, p 0.025). Additionally, newly diagnosed type-2 diabetes patients demonstrated lower mortality rate in comparison to previously known type-2 diabetes patients (18% vs 40%, p 0.005). Outcomes in the prediabetes group were similar to that in the control group. Admission hyperglycemia was associated with higher mortality regardless of diabetes status. CONCLUSION: In older patients aged 55 years and above, status of type-2 diabetes does not influence their mortality. However, in younger patients aged less than 55 years, the presence of type-2 diabetes is an important driver of mortality. Newly diagnosed type-2 diabetes, in comparison with previously diagnosed type-2 diabetes, may have better survival. Presence of prediabetes did not affect outcomes in patients with COVID-19 infection.

COVID-19 Vaccine Failure in a Patient with Multiple Sclerosis on Ocrelizumab.

Vaccines will play a key role in ending the COVID-19 pandemic. Vaccination against infections remains an important part of the management of patients with multiple sclerosis. However, there are limited data about the safety and efficacy of the currently available COVID-19 mRNA vaccines in patients with multiple sclerosis receiving concurrent immunosuppressive therapies. Patients on B cell depleting therapy such as ocrelizumab have an attenuated vaccine response. We report the first case of COVID-19 vaccine failure in a patient with relapsing-remitting multiple sclerosis on B cell depleting therapy, ocrelizumab. We offer suggestions to improve vaccine efficacy in these patients.

COVID-19 in the Healthy Patient Population: Demographic and Clinical Phenotypic Characterization and Predictors of In-Hospital Outcomes.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) can infect patients in any age group including those with no comorbid conditions. Understanding the demographic, clinical, and laboratory characteristics of these patients is important toward developing successful treatment strategies. Approach and Results: In a retrospective study design, consecutive patients without baseline comorbidities hospitalized with confirmed COVID-19 were included. Patients were subdivided into ≤55 and >55 years of age. Predictors of in-hospital mortality or mechanical ventilation were analyzed in this patient population, as well as subgroups. Stable parameters in overall and subgroup models were used to construct a cluster model for phenotyping of patients. Of 1207 COVID-19-positive patients, 157 met the study criteria (80≤55 and 77>55 years of age). Most reliable predictors of outcomes overall and in subgroups were age, initial and follow-up d-dimer, and LDH (lactate dehydrogenase) levels. Their predictive cutoff values were used to construct a cluster model that produced 3 main clusters. Cluster 1 was a low-risk cluster and was characterized by younger patients who had low thrombotic and inflammatory features. Cluster 2 was intermediate risk that also consisted of younger population that had moderate level of thrombosis, higher inflammatory cells, and inflammatory markers. Cluster 3 was a high-risk cluster that had the most aggressive thrombotic and inflammatory feature. CONCLUSIONS: In healthy patient population, COVID-19 remains significantly associated with morbidity and mortality. While age remains the most important predictor of in-hospital outcomes, thromboinflammatory interactions are also associated with worse clinical outcomes regardless of age in healthy patients.

Tocilizumab use in patients with moderate to severe COVID-19: A retrospective cohort study.

WHAT IS KNOWN AND OBJECTIVE: The coronavirus disease 2019 (COVID-19) associated cytokine activation can lead to a rapid progression into respiratory failure, shock and multiorgan failure. Interleukin-6 (IL-6) is a pro-inflammatory cytokine that likely contributes to the pathogenesis of cytokine release syndrome. It is hypothesized that modulating IL-6 levels or its effects with tocilizumab, a recombinant humanized anti-IL-6 receptor monoclonal antibody, may alter the course of disease. METHODS: We examined the association between tocilizumab use and intubation or death at a community hospital in New York City. Data were obtained regarding consecutive patients hospitalized with COVID-19. The primary end point was a composite of intubation or death in a time-to-event analysis. We compared outcomes in patients who received tocilizumab with those in patients who did not, using a multivariable Cox model with inverse probability weighting according to the propensity score. RESULTS AND DISCUSSION: In this single-centre retrospective cohort study involving 1225 hospitalized patients with SARS-CoV-2 infection, the probability to respiratory failure, which was measured as intubation or death, was less frequent in patients who received tocilizumab. WHAT IS NEW AND CONCLUSION: Tocilizumab and other IL-6 receptor monoclonal antibodies may evolve as a viable option in treating patients with moderate and severe COVID-19.

Association of smoking status with outcomes in hospitalised patients with COVID-19.

INTRODUCTION: Smoking causes inflammation of the lung epithelium by releasing cytokines and impairing mucociliary clearance. Some studies have linked smoking with severity of illness of COVID-19 whereas others have found no such association. METHODS: This was a retrospective analysis of all adults hospitalised with COVID-19 from 9 March to 18 May 2020. RESULTS: 1173 patients met the study criteria. 837 patients never smoked whereas 336 patients were either current smokers or past smoker and were grouped together in smokers group. Patients in smokers group were more likely to be male and had higher incidence of underlying chronic obstructive pulmonary disease (19% vs 6%, p<0.001), HIV infection (11% vs 5%,p<0.001), cancer (11% vs 6%, p=0.005), congestive heart failure (15% vs 8%, p<0.001), coronary artery disease (15% vs 9%, p=0.3), chronic kidney disease (11% vs 8%, p=0.037) and end-stage renal disease (10% vs 6%, p=0.009) compared with non-smokers. Outcome analysis showed that smokers were more likely to develop critical illness requiring mechanical ventilation (47% vs 37% p=0.005). Univariate Cox model for survival analysis by smoking status showed that among smokers only current smokers had higher risk of death compared with never smokers (HR 1.61, 95% CI 1.22 to 2.12, p<0.001). In the multivariate approach, Cox model for the survival, female sex, young age, low serum lactate dehydrogenase and systemic steroid use were associated with overall improved survival. CONCLUSION: In our large single-centre retrospective database of patients hospitalised with COVID-19, smoking was associated with development of critical illness and higher likelihood of death.

The Association of Renin-Angiotensin-Aldosterone System Inhibitors With Outcomes Among a Predominantly Ethnic Minority Patient Population Hospitalized With COVID-19: The Bronx Experience.

Background and objective Angiotensin-converting enzyme inhibitors (ACE) and angiotensin II receptor blockers (ARB) are commonly used for the treatment of patients with heart disease, hypertension (HTN), and diabetes mellitus (DM). In the aftermath of the emergence of the coronavirus disease 2019 (COVID-19) pandemic, initial data raised concerns that ACE/ARB use can increase the expression of ACE2 receptors, leading to the worsening of COVID-19. However, recent studies have suggested that their use might be safe in a select subgroup of patients. We conducted a single-center retrospective study to evaluate the association of in-patient use of ACE/ARB with outcomes among a predominantly ethnic minority patient population of the inner New York City (NYC). Methods This was a retrospective analysis of all hospital admissions with COVID-19 from March 1, 2020, to March 31, 2020. Results Of the 469 patients included in the study, 91 patients (19.4%) used ACE/ARB therapy during their hospital stay and were labeled as ACE/ARB group. Patients in the ACE/ARB therapy group were older and had a higher incidence of HTN, coronary artery disease (CAD), congestive heart failure, DM, asthma, and chronic obstructive pulmonary disease. Admission D-dimer, lactate dehydrogenase (LDH), and C-reactive protein (CRP) levels were similar between the two groups, but absolute lymphocyte count (ALC) was lower in the non-ACE/ARB group (0.971 k/ul vs. 1.135 k/ul, p=0.0144). The incidence of hyperkalemia and the rise in creatinine were similar between the two groups. Univariate analysis by treatment group using the log-rank test produced significant results (p=0.0062), indicating a higher survival rate for the ACE/ARB group. Conclusion The use of ACE/ARB appears to be safe in all patients in whom their use is medically indicated.

Predictors of Mortality in Adults Admitted with COVID-19: Retrospective Cohort Study from New York City.

INTRODUCTION: Rapid spread of coronavirus disease 2019 (COVID-19) in the United States, especially in New York City (NYC), led to a tremendous increase in hospitalizations and mortality. There is very limited data available that associates outcomes during hospitalization in patients with COVID-19. METHODS: In this retrospective cohort study, we reviewed the health records of patients with COVID-19 who were admitted from March 9-April 9, 2020, to a community hospital in NYC. Subjects with confirmed reverse transcriptase-polymerase chain reaction (RT-PCR) of the nasopharyngeal swab for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were included. We collected data related to demographics, laboratory results, and outcome of hospitalization. Outcome was measured based on whether the patient was discharged home or died during hospitalization. RESULTS: There were 888 consecutive admissions with COVID-19 during the study period, of which 513 were excluded with pending outcome or incomplete information. We included a total of 375 patients in the study, of whom 215 (57%) survived and 160 (43%) died during hospitalization. The majority of patients were male (63%) and of Hispanic origin (66%) followed by Blacks (25%), and others (9%). Hypertension (60%) stands out to be the most common comorbidity followed by diabetes mellitus (47%), cardiovascular disease (17%), chronic kidney disease (17%), and human immunodeficiency virus/acquired immunodeficiency syndrome (9%). On multiple regression analysis, increasing odds of mortality during hospitalization was associated with older age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01-1.06 per year increase; p < 0.0001), admission D-dimer more than 1000 nanograms per milliliter (ng/mL) (OR 3.16; 95% CI, 1.75-5.73; p<0.0001), admission C-reactive protein (CRP) levels of more than 200 milligrams per liter (mg/L) (OR 2.43; 95% CI, 1.36-4.34; p = 0.0028), and admission lymphopenia (OR 2.63; CI, 1.47-4.69; p 0.0010). CONCLUSION: In this retrospective cohort study originating in NYC, older age, admission levels of D-dimer of more than 1000 ng/mL, CRP of more than 200 mg/L and lymphopenia were associated with mortality in individuals hospitalized for COVID-19. We recommend using these risk factors on admission to triage patients to critical care units or surge units to maximize the use of surge capacity beds.