Association of excess visceral fat and severe illness in hospitalized COVID-19 patients in Japan: a retrospective cohort study.

BACKGROUND/OBJECTIVES: Obesity, defined by body mass index (BMI), is a well-known risk factor for the severity of coronavirus disease 2019 (COVID-19). Adipose tissue distribution has also been implicated as an important factor in the body's response to infection, and excess visceral fat (VF), which is prevalent in Japanese, may contribute significantly to the severity. Therefore, this study aimed to evaluate the association of obesity and VF with COVID-19 severe illness in Japan. SUBJECTS/METHODS: This retrospective cohort study involved 550 COVID-19 patients admitted to a tertiary care hospital with BMI and body composition data, including VF. The primary endpoint was severe illness, including death, due to COVID-19 during hospitalization. Logistic regression analysis was applied to examine the quartiles of BMI and VF on severe illness after adjusting for covariates such as age, sex, subcutaneous fat, paraspinal muscle radiodensity, and comorbidities affecting VF (COPD, cancer within 5 years, immunosuppressive agent use). RESULTS: The median age was 56.0 years; 71.8% were males. During hospitalization, 82 (14.9%) experienced COVID-19 severe illness. In the multivariate logistic regression analysis, Q4 of BMI was not significantly associated with severe illness compared to Q1 of BMI (OR 1.03; 95% CI 0.37-2.86; p = 0.95). Conversely, Q3 and Q4 of VF showed a higher risk for severe illness compared to Q1 of VF (OR 2.68; 95% CI 1.01-7.11; p = 0.04, OR 3.66; 95% CI 1.30-10.26; p = 0.01, respectively). Stratified analysis by BMI and adjusted for covariates showed the positive association of VF with severe illness only in the BMI < 25 kg/m2 group. CONCLUSIONS: High BMI was not an independent risk factor for COVID-19 severe illness in hospitalized patients in Japan, whereas excess VF significantly influenced severe illness, especially in patients with a BMI < 25 kg/m2.

Effectiveness of remdesivir with corticosteroids for COVID-19 patients in intensive care unit: A hospital-based observational study.

The effectiveness of remdesivir on survival in coronavirus disease 2019 (COVID-19), especially in cases treated in the intensive care unit (ICU), is controversial. We investigated the effectiveness of remdesivir with corticosteroids on the survival of COVID-19 patients in a real ICU clinical practice. For laboratory-confirmed COVID-19 patients admitted to the ICU of a tertiary hospital in Tokyo (April 2020-November 2021) and who received corticosteroids, the effectiveness of remdesivir for survival, stratified by interval length (within 9 or 10+ days), was retrospectively analyzed using Cox regression model. A total of 168 patients were included: 35 with no remdesivir use (control), 96 with remdesivir use within 9 days, and 37 with remdesivir use with an interval of 10+ days. In-hospital mortality was 45.7%, 10.4%, and 16.2%, respectively. After adjusting for possible covariates including comorbidities, laboratory data, oxygen demand, or level of pneumonia, remdesivir use within 9 days from symptom onset reduced mortality risk (hazard ratio [HR]: 0.10; 95% confidence interval (CI): 0.025-0.428) compared to the control group. However, remdesivir use with an interval of 10+ days showed no significant association with mortality (HR: 0.42; 95% CI: 0.117-1.524). Among COVID-19 patients who received corticosteroids in ICU, remdesivir use within 9 days from symptom onset was associated with reduced in-hospital mortality risk.

Newly Proposed Sepsis-Induced Coagulopathy Precedes International Society on Thrombosis and Haemostasis Overt-Disseminated Intravascular Coagulation and Predicts High Mortality.

BACKGROUND: Disseminated intravascular coagulation (DIC) has been recognized as an urgent and critical condition in patients with sepsis. Therefore, unfamiliar and time-consuming tests or a complex scoring system are not suitable for diagnosis. Sepsis-induced coagulopathy (SIC), a newly proposed category delineated by a few global coagulation tests, has been established as an early warning sign for DIC. The purpose of this study was to elucidate the characteristics of SIC, especially in relation to the score of the International Society on Thrombosis and Haemostasis (ISTH) for overt DIC. METHOD: A data set for 332 patients with sepsis who were suspected to have DIC, antithrombin activity <70%, and treated with antithrombin substitution was utilized to examine the relationship between SIC and overt DIC. The performance of SIC calculated at baseline (ie, before treatment) as well as on days 2, 4, or 7 was analyzed in terms of its ability to predict 28-day mortality and overt DIC. RESULTS: At baseline, 149 (98.7%) of 151 patients with overt DIC according to the ISTH definition were diagnosed as having SIC. Of the 49, 46 (93.9%) patients who developed overt DIC between days 2 and 4 had received a prior diagnosis of SIC. The sensitivity of baseline SIC for the prediction of death was significantly higher than that of overt DIC (86.8% vs 64.5%, P < .001). The sensitivity of SIC on days 2, 4, and 7 was significantly higher than those of overt DIC (96.1%, 92.3%, and 84.4% vs 67.1%, 57.7%, and 50.0%, P < .001, .001, and .001, respectively), although the specificity of SIC was lower at all time points.

Post-intubation laryngeal injury after COVID-19 treatment causing dyspnea: A report of six cases.

Severe cases of COVID-19 often require orotracheal intubation (OTI) and mechanical ventilation, and post-intubation laryngeal injury (PI-LI) is one of the important complications of OTI. Some studies have claimed that the frequency of PI-LI may be higher in COVID-19 patients as compared with that in non-COVID-19 patients, because of the larger size of endotracheal tube used, the longer OTI time, use of prone positioning of the patients, etc. Herein, we describe six cases of PI-LI who presented with dyspnea after recovering from COVID-19. Five of the patients were male and the median OTI period was 9 days. All the patients showed abnormal endoscopic findings, including posterior glottic synechiae/stenosis or subglottic/posterior glottic granulomas. Four patients required surgical intervention, including tracheostomy, laryngomicrosurgery, or laterofixation of the vocal cord. Many post-COVID-19 patients experience persistent symptoms (post-COVID-19 syndrome), including dyspnea. Two of our patients with dyspnea had been treated by internists as cases of post-COVID-19 syndrome. Therefore, we wish to underscore the need for every healthcare professional to be aware of the possibility of PI-LI after OTI, especially during the ongoing COVID-19 pandemic. Otolaryngologists should undertake endoscopic assessment of the larynx in patients presenting with dyspnea after recovering from COVID-19.

Effects of combination therapy using antithrombin and thrombomodulin for sepsis-associated disseminated intravascular coagulation.

BACKGROUND: No single anticoagulant has been proven effective for sepsis-associated disseminated intravascular coagulation (DIC). Thus, the concomitant use of antithrombin concentrate and recombinant thrombomodulin has been conceived. This observational study was conducted to investigate the efficacy and safety of this combination therapy. METHODS: A total of 510 septic DIC patients who received antithrombin substitution were retrospectively analyzed. Among them, 228 were treated with antithrombin and recombinant thrombomodulin (combination therapy) and the rest were treated with antithrombin alone (monotherapy). Propensity score matching created 129 matched pairs, and 28-day all-cause mortality, DIC scores, the sequential organ failure assessment (SOFA) scores, and the incidence of bleeding were compared. RESULTS: A log-rank test revealed a significant association between combination therapy and a lower 28-day mortality rate (hazard ratio 0.49, 95% confidence interval 0.29-0.82, P = 0.006) in the matched pairs. The DIC scores and the SOFA scores in the combination therapy group were significantly lower than those in the monotherapy group on Day 4 and Day 7. The incidence of bleeding did not differ between the groups (2.11 vs. 2.31%, P = 1.000). CONCLUSIONS: The current study demonstrated the potential benefit of adding recombinant thrombomodulin to antithrombin. The co-administration of these two anticoagulants was associated with reduced mortality among patients with sepsis-induced DIC without increasing the risk of bleeding.

Needs for disaster medicine: lessons from the field of the Great East Japan Earthquake.

PROBLEM: The Great East Japan Earthquake, which occurred in Tohoku, Japan on 11 March 2011, was followed by a devastating tsunami and damage to nuclear power plants that resulted in radiation leakage. CONTEXT: The medical care, equipment and communication needs of four Disaster Medical Assistance Teams (DMAT) during four missions are discussed. DMATs are medically trained mobile teams used in the acute phase of disasters. ACTION: The DMATs conducted four missions in devastated areas from the day of the earthquake to day 10. The first and second missions were to triage, resuscitate and treat trauma victims in Tokyo and Miyagi, respectively. The third mission was to conduct emergency medicine and primary care in Iwate. The fourth was to assist with the evacuation and screening of inpatients with radiation exposure in Fukushima. OUTCOME: Triage, resuscitation and trauma expertise and equipment were required in Missions 1 and 2. Emergency medicine in hospitals and primary care in first-aid stations and evacuation areas were required for Mission 3. In Mission 4, the DMAT assisted with evacuation by ambulances and buses and screened people for radiation exposure. Only land phones and transceivers were available for Missions 1 to 3 although they were ineffective for urgent purposes. DISCUSSION: These DMAT missions showed that there are new needs for DMATs in primary care, radiation screening and evacuation after the acute phase of a disaster. Alternative methods for communication infrastructure post-disaster need to be investigated with telecommunication experts.