Anaesthetic pre-assessment of obese patients in obstetrics: challenges in COVID recovery

Introduction: One in five pregnant women in the UKis obese. Obesity is associated with increased risk of both maternal and foetal adverse outcomes. RCOG guidelines [1] recommend that all women with a booking BMI over 40 kg/m2 should be reviewed antenatally by a senior obstetric anaesthetist to guide risk assessment, medical optimisation and shared decision-making. The 2021 MBRRACE report [2] recommends that all women should be reweighed in the third trimester for accurate VTE risk scoring and prophylactic LMWH dosing. In our institution, reconfiguration of hospital areas as part of the COVID-19 response led to loss of designated clinic space for our obstetric anaesthetic clinic. As a result, our practice since has been to initially offer a telephone consultation followed by a face-to-face review if needed. Finding space for the latter has often been a significant logistical challenge. Our project sought to assess whether our practice continued to meet national standards in the wake of these changes. Method(s): Following audit approval, we retrospectively reviewed all women with a BMI >40 kg/m2 undergoing caesarean section (CS) over a six-month period (1/4/22 to 31/9/22). Result(s): 20 women met inclusion criteria (Category 1-3 CS - 12 women;Category 4 CS - 8 women). 100% of patients had booking height, weight and BMI recorded. 20% (4/20) of patients were reweighed in the 3rd trimester. Only 55% (11/20) of patients had been referred to and reviewed in the antenatal obstetric anaesthetic clinic (Figure). Of the 11 patients referred, 6 were referred later than 30 weeks. Of the 9 patients not referred, 8 had a BMI between 40 and 45 kg/m2. By contrast, 87% (6/7) of patients with BMI over 45 kg/m2 were referred and seen. Discussion(s): Our audit showed that we are not meeting national standards. Possible reasons identified were lack of awareness of the RCOG standards and referral criteria (especially for women with a BMI of 40 to 45 kg/m2) and logistical issues in undertaking face-to-face reviews without designated clinic space. Presentation of our results at the joint anaesthetic, obstetric and midwifery governance meeting has helped identify space in the antenatal clinic for face-to-face reviews, to start from March 2023 and to raise awareness of the national standards to ensure referral of all women with a BMI over 40 kg/m2. A reaudit is planned in 6 months. [Figure presented]Copyright © 2023 Elsevier Ltd

Clinical and laboratory characteristics of SARS-CoV-2 infection in overweight and obese patients.

Objective. To assess the impact of obesity and overweight on the course of COVID-19. Patients and methods. This prospective study included 218 patients with SARS-CoV-2 infection aged 18 to 94 years hospitalized between June 2020 and March 2021. We evaluated their clinical and laboratory parameters and their association with body weight. All patients were divided into 3 groups depending on their body mass index (BMI). Group 1 included 81 patients with grade 1-3 obesity (BMI >=30);group 2 comprised 71 overweight patients (BMI >=25 and <30);group 3 included 66 patients with normal body weight (BMI >=18.5 and <25). We analyzed clinical symptoms (including shortness of breath, fever, myalgia, headache, fatigue, changes in the oropharynx, cough, rhinorrhea, sore throat, anosmia, and diarrhea), prevalence of concomitant disorders and complications, findings of computed tomography and pulse oximetry, and findings of instrumental and laboratory examinations (complete blood count, urine test, electrocardiography, echo cardiography, biochemical assays, including C-reactive protein, procalcitonin, alanine aminotransferase, aspartate aminotransferase, lactate, lactate dehydrogenase, activated partial thromboplastin time, prothrombin index, D-dimer, ferritin). Data analysis was performed using the Statistica 6.0 software. Results. We found that overweight and obese patients were more likely to have the main COVID-19 symptoms and comorbidities than those with normal weight. Overweight and obese patients also required respiratory support more frequently than patients with normal weight. Obese and overweight patients had more severe systemic inflammation (CRP, procalcitonin), cytolysis (ALT, AST), and thrombosis (D-dimer). Conclusion. Our findings suggest that obesity and overweight are the factors associated with a more severe SARS-CoV-2 infection, which should be considered when planning their treatment and developing resource strategies.Copyright © 2022, Dynasty Publishing House. All rights reserved.

VV-ECMO in critical COVID-19 obese patients

Objectives: Obesity is a condition prone to pose difficulties to a successful extra-corporeal membrane oxygenation (ECMO) support. Not being a contraindication, it yields significant challenges to physicians and may interfere with patient;s outcome. The number of obese patients supported by ECMO has increased during COVID-19 pandemic due to severe illness in this population. We designed a retrospective study in order to identify prognostic factors for 180-day survival in critical COVID-19 obese patients in venovenous ECMO (VV-ECMO). Method(s): Single-center retrospective cohort of critical COVID-19 adult patients in VV-ECMO, obese and overweight (according to WHO classification), admitted in a tertiary hospital;s ICU from April 1st 2020 to May 31th2022. Univariate logistic regression analysis was performed to assess 180-day mortality differences. Result(s): The analysis included 41 patients. The median [interquartile range (IQR)] age was 55 (IQR 45-60) years and 70,7% were male. Median body mass index (BMI) was 36 (IQR 31-42,5) Kg/m2 ;39% of patients had a BMI >=40 kg/m2 . The sampling had 3 (IQR 1,5-4) days of invasive ventilation prior to ECMO and 63,4% were weaned from ECMO-VV support after a median of 19 (IQR 10-34) days. The median ICU length of stay was 31,9 (IQR 17,5-44,5) days. The invasive ventilation period was 30 (IQR 19-49,5) days. The 60, 90 and 180-day mortalities were 41,5%. On the univariate logistic regression analysis we found that higher BMI was associated with higher 180-day survival (odds ratio [OR] 1,157 (1,038-1,291), p 0,009). Younger age, female patients, less invasive ventilation time prior to ECMO and fewer complications at time of ECMO cannulation were associated with higher 180-day survival [respectively, OR 0,858 (0,774- 0,953), p 0,004;OR 0,074 (0,008-0,650), p 0,019;OR 0,612 (0,401-0,933), p 0.022;OR 0.13 (0,03-0,740), p 0,022)]. Conclusion(s): In this retrospective cohort of critical COVID-19 obese adult patients supported by VVECMO, a higher BMI, younger age and female patients were associated with higher 180-day survival. A shorter invasive ventilation time prior to ECMO and fewer complications at ECMO cannulation were also associated with increased survival.

Provision of Diet, Exercise, Cholesterol and Hemoglobin A1C Testing in Office Based Medical Visits Among Normal, Overweight, Obese, and Morbidly Obese Individuals in the US

Objectives: Obesity is a global epidemic and leads to complications such as diabetes and dyslipidemia. The objective of this study was to examine the provision of diet, exercise, cholesterol and HbA1c testing in office based medical visits among normal, overweight, obese, and morbidly obese individuals in the US. Method(s): The 2018 National Ambulatory Medical Care Survey data was used to conduct the study. Main outcome was provision of diet/nutrition, exercise, weight-reduction counseling, cholesterol and HbA1c testing in normal (BMI:18-25), overweight (BMI:25-30), obese (BMI:30 - 40), and morbidly obese (BMI:40+) individuals. A logistic regression model was fit to examine main outcomes by BMI status. Survey weights are assigned to the sample visits to obtain national estimates. All models were adjusted for confounders: race, ethnicity, age, gender, MSA, and insurance status. Odds ratios are reported to describe differences in overweight, obese, and morbidly obese patients compared to normal weight patients. Result(s): The weighted study sample consisted of 496,622,621 outpatient visits primarily white (84%), male (58%), covered by private insurance (57%). Multivariate analysis reveals that overweight, obese, and morbidly obese individuals received more HbA1c tests (OR, 1.02;CI, 1.01-1.03;OR, 3.47;CI, 2.31-5.2;OR, 9.01;CI, 4.88-16.66), and lipid profile tests (OR, 1.56;CI, 1.01-2.41;OR, 1.88;CI, 1.32-2.67;OR, 2.16;CI, 1.20-3.90) compared to normal weight patients. Similar trends were observed in the provision of diet/nutrition, exercise, and weight reduction counseling services (OR, 3.31;CI, 1.49 -7.35;OR, 7.51;CI, 2.85 -19.76;OR, 18.47;CI, 7.40- 46.10). Conclusion(s): Our study findings suggest that at risk individuals receive more weight-related services, such as testing for diabetes, cholesterol, diet, exercise, and weight reduction education compared to normal weight individuals. This study forms a baseline to examine disparity in provision of such services post-Covid (2019 and beyond) era given the disruption in the scarcity of health care professionals for such basic preventive services.Copyright © 2023

Effect of obesity on Covid-19 anxiety and role of self-esteem on women in Turkish population

Background and aim: In this prospective study, it was aimed to evaluate effects of obesity on Covid-19 anxiety and role of self-esteem on women in Turkish population. Method(s): Obese (n = 184) and non-obese women (n = 219) who applied to our clinic in the first six months of 2020 were included in the study. The women included in the study were divided into two groups as having Body Mass Index (BMI) 30 or more obese according to the WHO criteria. Demographic information form, the Rosenberg Self-Esteem Scale and the Covid-19 Anxiety Scale was used for data collection. Result(s): Most of the obese participants were housewives, and the difference was statistically significant (p<0.05). Family obesity history was more common at obese group with statistically significant difference (p<0.05). Rosenberg self-esteem were lower and Covid-19 Anxiety levels were higher in obese patients with statistically significant differences (p<0.05). obesity, working status and family history were significantly correlated with Covid-19 anxiety (p<0.01). According to GLM model, only obesity had positive contribution to Covid-19 anxiety at multivariate level (p<0.05). The level of Covid-19 anxiety is higher in obese women, and the increase in self-esteem levels decreases this anxiety level. Conclusion(s): In order to reduce this burden, the news and content that indicate obesity as a risk factor in publications about the pandemic should be planned considering the self-esteem of these individuals.Copyright © Mattioli 1885.

Indirect Calorimetry Critical in Identifying Early Hypometabolism and Late-Stage Hypermetabolism in Post-surgical Patients

Background: Indirect calorimetry (IC) is the gold-standard procedure for measuring resting energy expenditure (REE) in hospitalized patients. Predictive energy equations commonly use static variables and rarely account for changes in REE throughout hospitalization. We hypothesize that predictive equations are typically inaccurate in surgical intensive care unit (ICU) patients. More specifically, we hypothesize that predictive equations often overpredict measured resting energy expenditure (mREE) in early-stage critical illness and underpredict needs later in surgical ICU stay, leading to over-/under-feeding and associated complications. Method(s): This prospective observational trial enrolled surgical ICU patients who underwent emergent or urgent operations for abdominal trauma, perforated viscus, or ischemic bowel within 72 hours of their surgical procedure. Metabolic assessments were performed using the COSMED Q-NRG + Metabolic Monitor ventilator, mask, and canopy at regular intervals during and post ICU admission until hospital discharge. Measurements were categorized by post-surgical intervention ICU admission days 0-3, 4-7, 8-14, 15-21, and 22-28. Patients with multiple measurements taken during the same time interval were averaged. mREE reported in calories (kcal) per kilogram (kg) of admission body weight per day were compared in obese (BMI > 30 kg/m2) and non-obese (BMI < 30 kg/m2) subgroups. Compared to IC, the Mifflin St Jeor (MSJ) equation determined predicted REE using ICU admission anthropometrics. Data are reported as mean+/-standard error of the mean (SEM) and median (interquartile range), and a two-sided p-value of <0.05 was determined significant. Result(s): In total, 18 surgical ICU patients who contributed 47 IC measurements were included in the analysis (Table 1). Most measures were obtained within the first 7 days of post-surgical ICU admission (72%). mREE peaked between days 8-14 in obese and non-obese subgroups (20.6 vs 28.5 kcal/kg;p = 0.02) and was lowest during 0-3 days of post-surgical ICU admission in both groups. Across all 5-time intervals, average kcal/ kg ranged from 14.7-20.6 among obese patients and from 20.1-28.5 in non-obese counterparts (Table 2). Non-obese patients had higher mREE per kg of body weight than obese patients at all time points (Figure 1). MSJ over-predicted mREE during the first 7 days post ICU admission in non-obese patients and within the first 3 days in obese patients and underpredicted mREE in both groups thereafter. Conclusion(s): Equations such as MSJ over- and under-predict mREE in post-operative surgical ICU patients depending on the days elapsed since post-surgical ICU admission. ASPEN's current guideline recommendation of 12-25 kcal/kg may also underfeed post-surgical populations while 25 kcal/kg may not support hypermetabolism among non-obese patients seen in week 2 following post-surgical ICU admission. Alternatively, MSJ multiplied by a 1.2 activity factor may account for hypermetabolism during this time. Notably, non-obese patients experienced greater hypermetabolism than obese patients during week 2 which is consistent with our previously published data in mechanically ventilated COVID- 19 patients. Additionally, the striking dichotomy between the mREE of obese and non-obese patients at all post-surgical time points should be considered in the clinical care of patients. Ultimately, IC remains the gold-standard means of measuring REE and is a critical tool to capture the dynamic nature of energy requirements in post-surgical populations as weight-based and predictive equations continually fall short. (Table Presented).

Clinical Nutrition in Covid-19 Patients-A Systematic Review

Introduction There is currently a lack of evidence on clinical nutrition in Covid-19. Aim of the work: Systematic overview of clinical nutrition in Covid-19. Material and methods A systematic literature search: 2 meta-analyses, 12 systematic reviews and meta-analyses, 9 prospective randomized controlled trials, 3 prospective observational studies, 7 retrospective studies, 25 narrative reviews. Results a) Obese patients have an increased risk of a severe course of the disease, b) there is a connection between obesity and an increased risk of death, c) Covid-19 mortality increases from a BMI>27 kg/m2, in all BMI classes 1,6% per 1 kg/m2 in the event of weight gain, in the case of severe obesity (> 40-45 BMI) by a factor of 1,5 to 2 and per 5 kg/m2, d) the risk of a severe course of Covid-19 increases also with increased visceral fat tissue percentage, total body fat mass and upper abdominal circumference, e) the mortality rate can be 10 times higher in malnourished Covid-19 patients, f) serum albumin provides evidence of a poor course of the disease, g) enteral omega-3 fatty acid intake could stabilize kidney function and improve the outcome, h) foods with a low glycemic index should be preferred, i) vitamin D deficiency should be avoided, daily vitamin D and zinc supplementation can be beneficial, j) one-time high dose vitamin D and enteral vitamin C provide no benefit, but the risk of thrombosis could be reduced and the antibody response enhanced with zinc, k) nutritional intervention reduces mortality. Conclusion Screening and assessment of nutritional status are important in Covid-19 patients. Overall, there are insufficient clinical results on specific nutritional therapy.Copyright © 2022 Georg Thieme Verlag. All rights reserved.

Pre-existing chronic liver disease is associated with poor outcome in patients with SARS-CoV2 infection

COVID-19 is characterized by predominant respiratory and gastrointestinal symptoms. Liver enzymes derangement is seen in 15-55% of the patients. Cirrhosis is characterized by immune dysregulation, leading to concerns that these patients may be at increased risk of complications following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients with metabolic dysfunction-associated fatty liver (MAFLD) had shown a 4-sixfold increase in severity of COVID-19, and its severity and mortality increased in patients with higher fibrosis scores. Patients with chronic liver disease had shown that cirrhosis is an independent predictor of severity of COVID-19 with increased hospitalization and mortality. An international European registry study included 756 patients with chronic liver disease from 29 countries reports high mortality in patients with cirrhosis (32%). Data of 228 patients collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19 (APCOLIS study) showed that SARSCoV- 2 infection produces acute liver injury in 43% of CLD patients without cirrhosis. Additionally, 20% of compensated cirrhosis patients develop either ACLF or acute decompensation. In decompensated cirrhotics, the liver injury was progressive in 57% of patients, with 43% mortality. Patients with CLD and associated diabetes and obesity had a worse outcome. Liver related complications were seen in nearly half of the decompensated cirrhotics, which were of greater severity and with higher mortality. Increase in Child Turcotte Pugh (CTP) score and model for end-stage liver disease (MELD) score increases the mortality in these patients. In a subsequent study of 532 patients from 17 Asian countries was obtained with 121 cases of cirrhosis. An APCOLIS risk score was developed, which included presence of comorbidity, low platelet count, AKI, HE and respiratory failure predicts poor outcome and an APCOLIS score of 34 gave a sensitivity and specificity of 79.3%, PPV of 54.8% and NPV of 92.4% and predicted higher mortality (54.8% vs 7.6%, OR = 14.3 [95 CI 5.3-41.2], p<0.001) in cirrhosis patients with Covid-19. The APCOLIS score is helpful in triaging and prognostication of cirrhotics with Coivd-19. The impact of COVID-19 on patients with cirrhosis due to non-alcoholic fatty liver disease (NASH-CLD) was separately studied in 177 NASH-CLD patients. Obese patients with diabetes and hypertension had a higher prevalence of symptomatic COVID. Presence of diabetes [HR 2.27], fraility [HR 2.68], leucocyte counts [HR 1.69] and COVID-19 were independent predictors of worsening liver functions in patients with NASH-CLD. Severity of Covid in Cirrhosis could also be assessed by measuring ICAM1 the Intercellular Adhesion Molecule, an indicator of Endothelial Injury Marker. in Cirrhosis with Covid 19 Immunosuppression should be reduced prophylactically in patients with autoimmune liver disease and post-transplantation with no COVID-19. Hydroxychloroquine and remdesivir are found to be safe in limited studies in a patient with cirrhosis and COVID-19. And is safe in cirrhosis patients. However, flare of AIH has been reported in AIH patients. For hepatologists, cirrhosis with COVID-19 is a pertinent issue as the present pandemic cause severe disease in patients with chronic liver disease leading to more hospitalization and decompensation.

Carbapenem Heteroresistance Mdr Enterobacter Cloacae in a Post-Covid-19 Obese Patient: An Antibiotic Susceptibility Conversion

Intro: Background: Obesity affects drug delivery and clearance owing to the patient's altered pharmacokinetics. In treating infection, this presents as a conundrum antibiotic dosing to achieve optimal antibiotic concentration at the same time avoiding drug toxicity. Particularly in the case of antimicrobial agents, underdosing may lead to antibiotic resistance. Method(s): Case description: We report a case of a morbidly obese (BMI=58) COVID-19 patient infected with carbapenem-sensitive multi-drug resistant (MDR) Enterobacter cloacae bacteremia, treated with ertapenem 1g twice daily and intravenous polymyxin E 9MU stat and 4.5MU twice daily for MDR Acinetobacter baumanii co-infection. He had infected huge grade IV sacral sore one month later in which intraoperative tissue culture grew phenotypically heterogeneous colonies of MDR Enterobacter cloacae with carbapenem-sensitive and carbapenem-intermediate-resistant non-carbapenemase producing colonies. He responded well clinically and biochemically with an increased dose of intravenous ciprofloxacin 800mg BD based on his actual body weight. He was discharged with oral ciprofloxacin 750mg BD for a total of six weeks. Finding(s): Discussion: Obesity is a public health crisis that has reached epidemic proportions. Obesity affects the volume distribution and renal clearance of many drugs including antibiotics. Obese patients are shown to have higher drug clearance than normal-weighted patients resulting in inadequate systemic exposure. This puts patients at risk of developing antibiotic resistant organisms. Our patient, weighing 162kg was given three different beta-lactam antibiotics to treat his infection including ertapenem in which a standard adult dose was given without body weight consideration. Possible underdosing contributed to the conversion of carbapenem susceptibility from sensitive to resistant strain. Conclusion(s): Obese individuals may need a larger ertapenem dose than their non-obese counterparts. Clinical and laboratory assessment may help in monitoring treatment response in this group of patients.Copyright © 2023

The State of the Obesity Paradox in 2020

Purpose of Study The detrimental long-term effects of obesity are well-described in literature;however, there has been recently emerging evidence describing a possible mortality benefit in obese patients with acute injury. The scope of this review is to provide an overview of the ongoing debate surrounding this observation. We focused our discussion on evaluating the evidences suggesting an impact of obesity and overweight on multiple acute medical conditions. Methods Used We searched the PubMed database with the keywords 'obesity', 'paradox', 'trauma', 'mortality', 'BMI', 'cancer', 'sepsis', 'lung injury', 'stroke', 'COVID', and 'myocardial infarct' from inception to 2020 and selected 40 relevant papers discussing the relationship between mortality and BMI in the setting of these stressors, and the mechanisms behind them. Summary of Results Amongst the fields of blunt trauma, cardiovascular disease, cancer, and critical care admissions for sepsis and lung injury, there are a growing amount of evidences supporting the existence of a paradoxical mortality benefit with overweight and mild obesity compared to normal and lean BMI. These findings must be attenuated with study design and BMI limitations, as well as biases prevalent throughout these studies. Although several hypotheses have been proposed, the exact mechanisms behind this relationship are largely unknown. Conclusions This survey of the obesity paradox shows promise in regard to overweight and mild obesity helping with survival post-acute illness, possibly due to metabolic reserves, antiinflammatory, and anti-oncogenic conditions seen in obesity. We recommend addressing current major limitations by having future studies prospectively designed to evaluate alternative body weight metrics such as waist-to-hip ratio or waist circumference, with special attention to the timing of body weight measurements and its progression in the patient's life. In the future, elucidating the biological mechanisms of this relationship may allow us to adapt our recommendations to the patients and help direct optimal therapeutic approach in the management of certain acute pathologies.

Clinical and laboratory characteristics of SARS-CoV-2 infection in overweight and obese patients.

Objective. To assess the impact of obesity and overweight on the course of COVID-19. Patients and methods. This prospective study included 218 patients with SARS-CoV-2 infection aged 18 to 94 years hospitalized between June 2020 and March 2021. We evaluated their clinical and laboratory parameters and their association with body weight. All patients were divided into 3 groups depending on their body mass index (BMI). Group 1 included 81 patients with grade 1-3 obesity (BMI >=30);group 2 comprised 71 overweight patients (BMI >=25 and <30);group 3 included 66 patients with normal body weight (BMI >=18.5 and <25). We analyzed clinical symptoms (including shortness of breath, fever, myalgia, headache, fatigue, changes in the oropharynx, cough, rhinorrhea, sore throat, anosmia, and diarrhea), prevalence of concomitant disorders and complications, findings of computed tomography and pulse oximetry, and findings of instrumental and laboratory examinations (complete blood count, urine test, electrocardiography, echo cardiography, biochemical assays, including C-reactive protein, procalcitonin, alanine aminotransferase, aspartate aminotransferase, lactate, lactate dehydrogenase, activated partial thromboplastin time, prothrombin index, D-dimer, ferritin). Data analysis was performed using the Statistica 6.0 software. Results. We found that overweight and obese patients were more likely to have the main COVID-19 symptoms and comorbidities than those with normal weight. Overweight and obese patients also required respiratory support more frequently than patients with normal weight. Obese and overweight patients had more severe systemic inflammation (CRP, procalcitonin), cytolysis (ALT, AST), and thrombosis (D-dimer). Conclusion. Our findings suggest that obesity and overweight are the factors associated with a more severe SARS-CoV-2 infection, which should be considered when planning their treatment and developing resource strategies.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Factors influencing user acceptance of weight management apps among Chinese obese individuals during the COVID-19 pandemic.

Background: During the COVID-19 epidemic, the number of obesities increased rapidly in China. Weight management apps have potential value in controlling obesity. Objective: Explore the mechanisms behind the adoption of weight management applications by overweight and obese individuals, including psychological factors and demographic variables. Methods: The theoretical model was extended from the technology acceptance model (TAM), and the structural equation model was used for hypothesis testing. From January 2020 to December 2021, we conducted a cross-sectional survey in six megacities in mainland China during the COVID-19 pandemic by an online questionnaire. Results: 1364 participants completed the questionnaire, and the proposed theoretical model explained 55.7% of the variance in behavioral intention. Perceived usefulness was predicted by perceived ease of use (ß = 0. 290), attitude was jointly predicted by perceived usefulness (ß = 0.118) and perceived ease of use (ß = 0.159). Behavioral intention was predicted by perceived usefulness (ß = 0. 256), perceived ease of use (ß = 0. 463), attitude (ß = 0. 293), and perceived risk (ß = -0.136). Health awareness (ß=0.016) did not significantly affect behavioral intention. Four demographic variables gender, age, education, and residence exerted significant moderating effects in theoretical model. Conclusions: During the COVID-19 epidemic, the health awareness and behavior patterns of obese people have changed significantly. Psychological factors and demographic characteristics dynamically interact to generate user behavioral intentions of weight management applications. Weight management application developers and marketers should focus on perceived usefulness, safety, ease of use, and health awareness.

Obesity and its impact on endotoxemia and systemic inflammation in acute SARS-CoV- 2 infection

Background: Given the coexistence of the COVID-19 pandemic and the worldwide epidemic of obesity, which in some Western countries affects up to 40% of the population, it is crucial today to understand the mechanisms involved in the worsening course of the new SARS-CoV- 2 coronavirus infection in obese patients. So-called "metabolic endotoxemia" associated with excess body weight and obesity may be one of the most important factors potentiating the effect of SARS-CoV- 2 virus influencing the prognosis of the disease. Method(s): 55 patients with SARS-CoV- 2 infection of moderate severity (patients with normal body mass index (BMI) -10;patients with BMI > 25 kg/m2 -19 and patients with BMI > 30 kg/m2 -26) and 20 controls were studied. Lipopolysaccharide binding protein (LBP), sCD14-ST and C-reactive protein (CRP) levels were measured by ELISA in plasma of patients taken on the day of admission to the hospital. Result(s): The plasma LBP (mug/ml) level was significantly greater in the group of patients with BMI > 30 kg/m2 (Me [Q1;Q3]) -52.5 [31.16;75.0], than in groups with BMI > 25 kg/m2 -48.3 [10.6;60] (p < 0.05), normal BMI -33.5 [8.3;54.8] (p < 0.01) and control group -18.6 [15.2;20.5] (p < 0.001). The plasma sCD14-ST (pg/ml) levels in the 2nd (2400.0 [1200.0;2900.0]) and 3rd (2100.0 [1290.0;1340.0]) group did not differ significantly (p > 0.05), but was significantly greater than in group with normal BMI -1310.0 [720.0;2325] (p < 0.05) and the control group -218.0 [80.0;292.0] (p < 0.01). The plasma CRP (mg/L) levels in the 1st (31.1 [9.3;51.0]) and 2nd (31.8 [15.7;57.3]) group did not differ significantly (p > 0.05), but was significantly less than in the group with BMI > 30 kg/m2 -40.5 [26.6;60.0] (p < 0.05) and the control group -0.5 [0.3;0.9] (p < 0.001). Conclusion(s): The phenomenon of "metabolic endotoxemia" in overweight and obese patients may contribute to the formation of high systemic inflammation in SARS-CoV- 2 virus-associated endothelial dysfunction and thrombotic microangiopathy.

Spirulina for Protection Against COVID-19 via Regulating ACE2, FNDC5, and NLRP3: A Triple-Blind Randomized Placebo-Controlled Trial in Obese Adults

Background: Spirulina may protect individuals against viral infections and promote health in obese subjects. This study is designed to investigate the impacts of spirulina on obesity to find a hope to protect this population against COVID-19. Material(s) and Method(s): In a double-blinded randomized placebo-controlled trial, 24 obese subjects (Mean age: 44.83+/-3.04 years;mean weight: 111.95+/-22.55kg;body mass index (BMI): 40.31+/-6.03kg/m2) were randomly allocated to spirulina (n=12) or control (Co, n=12) groups. Spirulina was administered 2 gr/day for 8 weeks and the Co group received a placebo for a similar period. Before and after the administration of spirulina, the anthropometric measurements were calculated for each subject. Furthermore, ACE2, NLRP3, and FNDC5 gene expression were examined in adults with obesity. Result(s): Our findings demonstrated that spirulina could not effective in normalizing body weight (BW), BMI, and waist-hip ratio (WHR). Spirulina administration significantly upregulated the gene expression of FNDC5 and significantly reduced NLRP3 and ACE2 gene expression in obese subjects compared with the Co-group. Furthermore, by increasing FNDC5 the gene expression of NLRP3 and ACE2 was significantly reduced. Conclusion(s): While administration of spirulina for eight weeks could not affect the anthropometric measurements, it showed the greatest impact on the gene expression of NLRP3, ACE2, and FNDC5, emplacing its potential in the protection of obese cases against COVID-19.Copyright © 2023 Journal of Cellular & Molecular Anesthesia. All rights reserved.

The effect of COVID-19 on vascular elasticity and liver function in overweight patients.

Objective. To study the changes in the vascular wall, vascular age and metabolic parameters in polymorbid COVID-19 conva-lescents. Material and methods. The study included 62 patients with hypertension who reached the target blood pressure (BP) with dual an-tihypertensive therapy after severe and extremely severe COVID-19. The following examinations were performed: laboratory tests of metabolic parameters, assessment of changes in the vessel elasticity indices (pulse-wave velocity (PWV), augmentation index (AI), central systolic BP (cSBP), 24-hour BP monitoring, and non-invasive markers of liver fibrosis. Results. According to office BP measurements, after the coronavirus infection, an increase in systolic BP (SBP) by 29.6% and di-astolic BP (DBP) by 23.6%, as well as heart rate (HR) by 11.8% (p<0.05) was reported during regular antihypertensive therapy. In addition, 24-hour BP monitoring data indicated an increase in the average daily SBP, DBP, and heart rate. After the coronavirus infection, an increase in PWV by 35.4% (p<0.05), AI by 24.4% (p<0.05), cSBP by 22.1% were reported. Carbohydrate and lipid metabolism parameters deteriorated. A pronounced adverse effect of coronavirus infection on liver function was observed. The vascular age (according to the modified SCORE scale) increased by 6 years (p<0.05). Conclusion. Our study showed that patients after severe and extremely severe COVID-19 have a high risk of liver fibrosis, hypertension and lipid metabolism control worsening and accelerating vascular aging.Copyright © 2023, Media Sphera Publishing Group. All rights reserved.

Impact of SARS-CoV2 infection in asthmatic patients at the Hospital La Paz in Madrid

Background: COVID-19 is an infectious disease caused by the SARS-CoV- 2 virus. It presents a wide clinical spectrum from asymptomatic cases to severe pneumonia and even death. Since the report of its first cases in 2019, risk factors for mortality or clinical failure have been described. Asthma, as a respiratory disease, could be a risk factor for developing severe COVID-19 disease. Thus, the aim of this study was to evaluate the impact of COVID-19 disease in asthmatic patients Method: 173 electronic medical records (DXC-HCIS- Healthcare Information System) of asthmatic patients were individually reviewed and demographic and clinical data were extracted: sex, age, smoking habit, comorbidities (obesity, rhinosinusitis, nasal polyps, COPD and T2 or non T2-asthma), previous asthma treatment (inhaled therapy, oral corticosteroids (OCS), biological therapy, azithromycin and anti-leukotriene use), number of previous exacerbations, blood eosinophils and serum Total-IgE levels. Severity of infection was registered according to the presence of pneumonia, need for hospitalization, intensive care unit (ICU) admission and mortality. Result(s): Higher risk of pneumonia was found in males (p = 0.004), smokers (p = 0.025) and previous treatment with inhaled corticosteroids (ICS) + long-acting s-agonist (LABA) (p = 0.001). We did not find higher risk of pneumonia for obesity, COPD, T2 asthma, OCS treatment, or previously elevated number of exacerbations or eosinophils (> 250/mcl). Higher risk of hospitalization was found among males (p = 0.048), smokers (p < 0.001) or patients with previous ICS+LABA treatment (p = 0.003) and lower risk of hospitalization in T2 asthmatic patients (p = 0.002) and those previously treated with ICS (p = 0.005). Although there were non-significant associations, there was a relation between obese patients and hospitalization risk (p = 0.064). There was no increased risk of death or ICU admission in asthmatic patients adjusted for gender, smoking, obesity, T2 asthma, type of previous treatment and number of exacerbations Conclusion(s): Asthmatic patients present a higher risk of pneumonia and hospitalization if they are male, smokers or undergoing ICS+ LABA treatment. Asthmatics with T2 asthma and previous treatment with ICS alone have a lower risk of hospitalization. Further studies with a higher number of patients are needed to explore deeply the impact of COVID-19 on asthma outcomes.

Prospective study of pulmonary embolism in patients with SARS CoV-2 pneumonia with high levels of D Dimer

Pulmonary embolism (PE) is common among hospitalized adults with SARS CoV-2 pneumonia. D-dimer (DD)>1 mug/mL has been found to be a severity risk factor. However, most of the studies are based on retrospective data and the real prevalence is unknown Objectives: To evaluate the prevalence of PE in patients with SARS CoV-2 pneumonia, regardless clinical suspicion. Demographic and laboratory data, comorbidities, and clinical outcomes were compared between patients with and without PE Methods: Single-center prospective study. All consecutive cases of SARS CoV-2 pneumonia with DD>1 mug/mL underwent computed tomography pulmonary angiography Results: 179 patients (64 (55-74 years), 65% male) were included. PE was diagnosed in 71 patients (39.7%), mostly with a peripheral location and low thrombotic load (Qanadli score 10%). We did not find disparity in PE prevalence between men and women, and between obese and not obese patients. There were no differences in the intensive care unit admission rate. Mortality rate was 8.5% in patients with PE vs. 3.7% in those without PE, but the differences were not significant. Patients with PE had more history of cardiovascular disease and required more fractional inspired oxygen. DD, platelet distribution width (PDW), neutrophil-lymphocyte ratio (NLR), DD-lactate dehydrogenase ratio (DD/LDH), and DD-ferritin ratio values were significantly higher among PE patients. ROC analysis showed that PDW and DD/LDH had the greatest area under the curve Conclusion(s): Patients with SARS CoV2 pneumonia and DD>1mug/mL presented a high prevalence of PE, regardless of clinical suspicion. PDW, NLR, DD/LDH and DD/Ferritin may help to identify patients with high risk of PE.

Perindopril Reduce SARS-COV-2 Spike-ACE2 Binding, ACE2 Overexpression and Cytokine Storm in Adipocyte Cell Infected with SARS-COV-2

Background and Aims: The SARS-CoV-2 virus can infect adipocyte cells via ACE2 Receptor thus triggering ACE2 overexpression and cytokine storms which cause lethal complications. Hence, we explore the effect of Perindopril on the expression of ACE2, IL-6, IL-1B TNF-alpha in adipocyte cultures infected by SARS-CoV-2 spike protein and identify the possible mechanism involved. Material(s) and Method(s): Adipocyte culture obtained from a healthy and obese donor was divided into 4 triplicate groups (P0: negative control without treatment;P1: positive control (SARS-CoV-2 spike protein);P2: SARS-CoV-2 spike protein + exposure to Perindopril 0.5 muM);P3: SARS-CoV-2 spike protein + anti-ACE2 antibody 100 mug/mL;and evaluated at 24 and 48 hours. ACE2 expression was evaluated using immunofluorescence. IL-6, TNFalpha, and IL-1B were evaluated using ELISA. SARS-COV-2 Spike-ACE2 Binding was evaluated using Competitive ELISA. Data analysis was performed using SPSS 25.0 software. Result(s): At first 24 hours of incubation, perindopril treatment has the highest ACE2 expression compared to negative control, positive control and anti-ACE2 antibody (113.52+/-0.34 ng/mL vs 13.3+/-0.87 ng/mL, 90.2+/-2.73 ng/mL, 17.3+/-0.11 ng/mL, p<0.01), lower ACE-ACE2R binding compared to anti-ACE2 antibody group (169.52+/-4.07 ng/mL vs 290.71+/-6.22 ng/mL, p<0.01) and higher IL-6 expression compared to positive control group (64.65+/-0.12 ng/mL vs 60.08+/-0.77 ng/mL p<0.01). Interestingly, after 48 hours, perindopril treatment was shown to prevent further increase of ACE2 expression compared to a positive control (47.37+/-0.76 ng/mL vs 80.31+/-5.37 ng/mL, p<0.01), higher SARS-COV-2 Spike-ACE2 binding compared to anti-ACE2 antibody group (143.68+/-3.68 ng/mL vs 103.1+/-9.49 ng/mL, p<0.01), and lower IL-6 expression compared to the positive control group (42.66+/-1.94 ng/mL vs 90.93+/-2.48 ng/mL p<0.01). However, no significant difference in TNFalpha and IL-1B expression between perindopril treatment and positive control in both 24 and 48 hours. Conclusion(s): This study showed that perindopril reduces cytokine storm by preventing ACE-2 and IL-6 overexpression via an increasing number of SARS-COV-2 Spike-ACE2 competitive binding in adipocyte culture infected with SARS-COV-2 spike protein. A further clinical trial is needed to prove the benefit of perindopril in obese patients with COVID-19.

Obesity and COVID-19: insights from two pandemics.

This review article discusses the pathophysiological mechanisms of the development of coronavirus infection in obese patients. It has been shown that obesity is considered as the most important risk factor for the development of many comorbid diseases, including severe forms and deaths as a result of a new coronavirus infection. The higher incidence and severity of a new coronavirus infection in obese patients is based on a complex of factors, the main of which are an increase in cardiovascular risk, including a tendency to thrombosis, a decrease in the efficiency of the respiratory system, impaired immune response, and the presence of chronic inflammatory state. The article discusses non-drug approaches and issues of pharmacological therapy in patients with obesity in the context of a pandemic of a new coronavirus infection. It is shown that the implementation of national quarantine measures has led to an increase in physical inactivity, the level of stress and a change in the eating behavior of the population, closing a vicious circle and contributing to an increase in body weight. For this reason, the efforts of physicians of therapeutic specialties should be directed primarily to increasing resistance to infection among obese patients and combating physical inactivity. The main groups of drugs that can be used to combat lipotoxicity are listed. It was noted that infectious disease doctors and endocrinologists can use those groups of drugs that affect the most vulnerable pathogenetic triggers for the development of obesity and comorbidities: hunger and satiety processes, decreased insulin sensitivity, development of lipotoxicity and chronic inflammation. It has been proven that the range of positive effects of new antihyperglycemic drugs from the groups of type 1 glucagon-like peptide agonists and type 2 sodium-glucose transporter inhibitors, combined with a well-studied efficacy and safety profile, represents a new opportunity for the treatment of obesity in the context of a coronavirus infection pandemic.Copyright © 2022 Authors. All rights reserved.

Obesity and COVID-19: insights from two pandemics.

This review article discusses the pathophysiological mechanisms of the development of coronavirus infection in obese patients. It has been shown that obesity is considered as the most important risk factor for the development of many comorbid diseases, including severe forms and deaths as a result of a new coronavirus infection. The higher incidence and severity of a new coronavirus infection in obese patients is based on a complex of factors, the main of which are an increase in cardiovascular risk, including a tendency to thrombosis, a decrease in the efficiency of the respiratory system, impaired immune response, and the presence of chronic inflammatory state. The article discusses non-drug approaches and issues of pharmacological therapy in patients with obesity in the context of a pandemic of a new coronavirus infection. It is shown that the implementation of national quarantine measures has led to an increase in physical inactivity, the level of stress and a change in the eating behavior of the population, closing a vicious circle and contributing to an increase in body weight. For this reason, the efforts of physicians of therapeutic specialties should be directed primarily to increasing resistance to infection among obese patients and combating physical inactivity. The main groups of drugs that can be used to combat lipotoxicity are listed. It was noted that infectious disease doctors and endocrinologists can use those groups of drugs that affect the most vulnerable pathogenetic triggers for the development of obesity and comorbidities: hunger and satiety processes, decreased insulin sensitivity, development of lipotoxicity and chronic inflammation. It has been proven that the range of positive effects of new antihyperglycemic drugs from the groups of type 1 glucagon-like peptide agonists and type 2 sodium-glucose transporter inhibitors, combined with a well-studied efficacy and safety profile, represents a new opportunity for the treatment of obesity in the context of a coronavirus infection pandemic.Copyright © 2022 Authors. All rights reserved.