Obesity and the obesity paradox in patients with severe COVID-19 / Obesidad y paradoja de la obesidad en pacientes con COVID-19 severo: Resultados de dos cohortes prospectivas

Objective: To test the presence of the obesity paradox in two cohorts of patients hospitalized for COVID-19. Design: Two multicenter prospective cohorts. Setting: Three fourth level institutions. Patients: Adults hospitalized in the general ward for confirmed COVID-19 in the three institutions and those admitted to one of the 9 critical care units of one of the institutions. Interventions: None. Main variables of interest: Categorized weight and its relationship with admission to the ICU in hospitalized patients and death in the ICU. Result: Of 402 hospitalized patients, 30.1% were obese. Of these, 36.1% were admitted to the ICU vs. 27.1% of non-obese patients. Of the 302 ICU patients, 46.4% were obese. Of these, mortality was 45.0% vs. 52.5% for non-obese. The requirement to transfer hospitalized patients to the ICU admission get a HR of 1.47 (95%CI 0.87–2.51, p = 0.154) in the multivariate analysis. In intensive care patients, an HR of 0.99 (95%CI: 0.92–1.07, p = 0.806) was obtained to the association of obesity with mortality. Conclusions: The present study does not demonstrate an association between obesity and risk of inpatient transfer to intensive care or death of intensive care patients due to COVID-19 therefore, the presence of an obesity paradox is not confirmed. (AU)

Objetivo: Comprobar la presencia la paradoja de la obesidad en dos cohortes de pacientes hospitalizados por COVID-19. Diseño: Dos cohortes prospectivas multicéntricas. Ámbito: Tres instituciones de cuarto nivel. Pacientes: Adultos hospitalizados en pabellón general por COVID-19 confirmado en las tres instituciones y aquellos internados en alguna de las 9 unidades de cuidado crítico de una de las instituciones. Intervenciones: Ninguna. Variables de interés principales: El peso categorizado y su relación con el ingreso a UCI en hospitalizados y de muerte en UCI. Resultado: Entre 402 hospitalizados 30.1% fueron obesos, de los que 36.1% ingresaron a UCI vs. 27.1% en los no obesos. De los 302 pacientes en UCI, el 46.4% fueron obesos, entre ellos la mortalidad fue de 45.0% vs. 52.5% en los no obesos. En hospitalizados el análisis multivariado obtuvo HR de 1.47 (IC95% 0.87–2.51, p = 0.154) para traslado a UCI. En UCI se obtuvo un OR de 0.99 (IC95%: 0.92–1.07, p = 0.806) para la muerte. Conclusiones: El presente estudio no demuestran una asociación entre la obesidad y el riesgo de traslados a cuidados intensivos en pacientes hospitalizados ni con la muerte en pacientes en cuidados intensivos por COVID-19 por lo que no se confirma la presencia de una paradoja de la obesidad. (AU)

Obesity and the obesity paradox in patients with severe COVID-19.

OBJECTIVE: To test the presence of the obesity paradox in two cohorts of patients hospitalized for COVID-19. DESIGN: Two multicenter prospective cohorts. SETTING: Three fourth level institutions. PATIENTS: Adults hospitalized in the general ward for confirmed COVID-19 in the three institutions and those admitted to one of the 9 critical care units of one of the institutions. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Categorized weight and its relationship with admission to the ICU in hospitalized patients and death in the ICU. RESULT: Of 402 hospitalized patients, 30.1% were obese. Of these, 36.1% were admitted to the ICU vs. 27.1% of non-obese patients. Of the 302 ICU patients, 46.4% were obese. Of these, mortality was 45.0% vs. 52.5% for non-obese. The requirement to transfer hospitalized patients to the ICU admission get a HR of 1.47 (95%CI 0.87-2.51, p = 0.154) in the multivariate analysis. In intensive care patients, an HR of 0.99 (95%CI: 0.92-1.07, p = 0.806) was obtained to the association of obesity with mortality. CONCLUSIONS: The present study does not demonstrate an association between obesity and risk of inpatient transfer to intensive care or death of intensive care patients due to COVID-19 therefore, the presence of an obesity paradox is not confirmed.

Early warning scores to identify the risk of clinical worsening or death in patients hospitalized for COVID-19

Background: identifying patients at risk for negative outcomes is key for performing a timely triage and adapting the care intensity for patients with COVID-19. Early warning scores are rules that alert to the risk of adverse outcomes during hospitalization. We sought to validate the modified NEWS, NEWS-2 and COVID-19 Severity Index (CSI). Methods: a prospective observational multicenter study of patients hospitalized for CO VID-19 at three quaternary care hospitals in Bogotá, Colombia, between April and November 2020. The operating characteristics and areas under the ROC curve were calculated. Results: 711 patients were included, in whom the AUC for death was 0.68, 0.58 and 0.68, and for ICU admission was 0.61, 0.63 and 0.66 for mNEWS, NEWS-2 and CSI, respectively. The CSI had the greatest sensitivity for ICU admission or death (87.6 and 90.0%) and NEWS-2 had the greatest specificity (76.8 and 75.5%). Conclusions: the three early warning scores had a low to moderate performance in pre dicting ICU admission or death in patients hospitalized for COVID-19. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2225).

Antecedentes: la identificación de los pacientes con riesgo de desenlaces negativos es clave para realizar un triage oportuno y adecuar la intensidad de los cuidados en los pacientes con COVID-19. Las puntuaciones de alerta temprana son reglas para advertir el riesgo de desenlaces adversos durante la hospitalización. Buscamos validar el NEWS modificado, NEWS-2 y COVID-19 Severity Index. Metodología: estudio observacional, prospectivo, multicéntrico con pacientes hospitalizados por COVID-19 en tres hospitales de cuarto nivel en Bogotá (Colombia), entre abril y noviembre de 2020. Se calcularon las características operativas y áreas bajo la curva ROC. Resultados: se contó con 711 pacientes entre los cuales el AUC para muerte fue 0.68, 0.58 y 0.68, y para ingreso a UCI de 0.61, 0.63 y 0.66 para NEWSm, NEWS-2 y CSI respectivamente. El CSI alcanzó la mayor sensibilidad para ingreso a UCI o muerte (87.6 y 90.0%) y la mayor especificidad fue el NEWS-2 (76.8 y 75.5%). Conclusiones: las tres puntuaciones de alerta temprana mostraron un desempeño bajo a moderado para la predicción del ingreso a UCI o muerte en pacientes hospitalizados por COVID-19. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2225).

Coinfección por Cryptococcus neoformans en paciente trasplantado renal con COVID-19 / Cryptococcus neoformans co-infection in a kidney transplant patient with COVID-19

Resumen La infección por el síndrome respiratorio agudo severo por coronavirus 2 (SARS-CoV-2), causante de la enfermedad COVID-19, representa una de las emergencias sanitarias más deletéreas de las últimas dos décadas; de la que aún existen innumerables incógnitas acerca del curso y manejo de presentaciones atípicas. Por lo anterior, resulta importante publicar casos clínicos de interés en población especial como lo son los pacientes receptores de trasplante renal, quienes pueden tener un mayor riesgo de contraer la enfermedad dado su estado de inmunosupresión, así como por el contacto frecuente con el sistema de atención médica. La coinfección con otros virus respiratorios no es infrecuente en población trasplantada con COVID-19, y la asociación con gérmenes oportunistas como Micobacterias, Citomegalovirus, Pneumocystis jirovecii y hongos, tal como el Cryptococcus neoformans es desconocida, pero es posible que dicha asociación pudiese empeorar la severidad del compromiso sistémico y pulmonar. Se presenta el caso de un hombre de 45 años, con antecedentes de trasplante renal de donante cadavérico, que ingresó al servicio de urgencias del Hospital de San José; el presentó síndrome de dificultad respiratoria aguda (SDRA) y falla ventilatoria por infección por SARS-CoV-2. Además, se confirmó infección sistémica por Cryptococcus neoformans sin compromiso del sistema nervioso central. Se inició manejo con ventilación mecánica invasiva, glucocorticoide, anfotericina B liposomal; fallece a los 12 días de su ingreso.

Abstract The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes the disease COVID-19, represents one of the most deleterious health emergencies of the last two decades; of which there are still innumerable unknowns about the course and handling of atypical presentations. Therefore, it is important to publish clinical cases of interest in a special population, such as kidney transplant recipients, who may have a greater risk of contracting the disease due to their immunosuppression and frequent contact with the medical care system. Co-infection with other respiratory viruses is not uncommon in the transplanted population with COVID-19, and the association with opportunistic germs such as Mycobacteria, Cytomegalovirus, Pneumocystis jirovecii and fungi, such as Cryptococcus neoformans, is unknown, yet it is possible that this association could worsen the severity of the systemic and pulmonary involvement. We present the case of a 45-year-old deceased-donor kidney transplant recipient man who was admitted to the emergency service; he presented acute respiratory difficulty syndrome (ARDS) and ventilatory failure due to infection by SARS-CoV-2. It was also confirmed that he had systemic infection by Cryptococcus neoformans without compromise of the central nervous system. It was necessary to use invasive mechanical ventilation, glucocorticoid, liposomal amphotericin B; he died 12 days after admission.