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      Does MAFLD really increase the severity of COVID-19?

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          Abstract

          Dear Editor, We read with great interest the meta-analysis by Pan et al [1] entitled “Metabolic associated fatty liver disease increases the severity of COVID-19” published in Digestive and Liver Disease. The article provides new information on the risk of severe COVID-19. There is evidence suggesting that comorbidities such as hypertension, diabetes mellitus, and cardiovascular diseases are associated with COVID-19 severity (https://covid19.who.int/). In their article, the authors found that individuals with metabolic associated fatty liver disease (MAFLD) also have a high risk to develop a severe condition when infected by COVID-19, [odds ratio (OR): 2.93; 95% confidence interval (95%CI): 1.87, 4.60]. We found that the study has several limitations that should be clarified. First, the article includes several letters to the Editor. At least four [2], [3], [4], [5] out of six papers [2], [3], [4], [5], [6], [7] are letters to the Editor. Although the Newcastle-Ottawa scale (NOS) was used to assess the quality of the included papers, which had moderate to high quality, the vast majority of meta-analysis studies excluded letters to the Editor. Referring to guideline from Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [8], reviews, commentaries, and letters to the Editor should be excluded. Nevertheless, since they have moderate-high quality based on the NOS criteria, these articles might be tolerable for inclusion in the meta-analysis. Second, two [2,4] out of six papers [2], [3], [4], [5], [6], [7] do not provide sufficient data for meta-analysis. The data of MAFLD prevalence in both severe and mild-moderate COVID-19 are insufficient to calculate the correlation and effect estimates. In the study by Zou et al [2] for example, the data are presented as total cases of severe COVID-19 and total cases of MAFLD. The data on how many MAFLD patients developed severe and mild - moderate COVID-19 were not presented. Therefore, the calculation of cumulative effect estimates, and the correlation was impossible to perform, and this article should be excluded. Moreover, in the study by Targher et al [4], the available data are only the number of MAFLD patients with neutrophil-to-lymphocyte ratio (NLR) ≤ 2.8 and NLR > 2.8. NLR is not the indicator of COVID-19 severity. The indicators of COVID-19 severity include any of the following criteria: respiratory distress (RR ≥ 30/min), oxygen saturation ≤ 93% at rest, and arterial partial pressure of oxygen (PaO2) / fraction of inspiration O2 (FiO2) ≤ 300 mnHg [9]. Therefore, we consider that this article does not meet the criteria to define severe COVID-19 and should be excluded. We re-analyzed the data after excluding those two papers and found that patients with MAFLD had a 6-fold higher risk of developing severe COVID-19 compared to those without MAFLD,(OR: 6.66; 95%CI: 2.84, 15.64) (Fig 1 ). Although our analysis is consistent with Pan et al [1], our analysis highlights a higher risk. Figure 1 Forest plot of the association between MAFLD and the risk of severe COVID-19 (OR: 6.66; 95%CI: 2.84, 15.64; p: <0.0001; p Heterogeneity: 0.0810; I squared: 56%; p Egger: 0.6440). Figure 1 We believe that study by Pan et al [1] provides important information on COVID-19 management, particularly in patients with MAFLD. This study suggests that MAFLD patients should be allocated to high monitoring due to the high likelihood of developing severe COVID-19. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Declaration of Competing Interest None of the authors has any conflicts to declare.

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          The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

          Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
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            Coronavirus Disease 2019 (COVID-19): A Perspective from China

            Abstract In December 2019, an outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection occurred in Wuhan, Hubei Province, China and spread across China and beyond. On February 12, 2020, WHO officially named the disease caused by the novel coronavirus as Coronavirus Disease 2019 (COVID-19). Since most COVID-19 infected patients were diagnosed with pneumonia and characteristic CT imaging patterns, radiological examinations have become vital in early diagnosis and assessment of disease course. To date, CT findings have been recommended as major evidence for clinical diagnosis of COVID-19 in Hubei, China. This review focuses on the etiology, epidemiology, and clinical symptoms of COVID-19, while highlighting the role of chest CT in prevention and disease control. A full translation of this article in Chinese is available in the supplement. - 请见䃼充资料阅读文章中文版∘
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              Non-alcoholic fatty liver diseases in patients with COVID-19: A retrospective study.

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                Author and article information

                Journal
                Dig Liver Dis
                Dig Liver Dis
                Digestive and Liver Disease
                Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd.
                1590-8658
                1878-3562
                11 November 2020
                11 November 2020
                Affiliations
                [a ]Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang 65145, Indonesia
                [b ]Division of Gastro-Entero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang 65117, Indonesia
                [c ]Faculty of Medicine, Universitas Sebelas Maret, Surakarta 57126, Indonesia
                [d ]Faculty of Medicine, Universitas Brawijaya, Malang 65117, Indonesia
                Article
                S1590-8658(20)30998-1
                10.1016/j.dld.2020.10.042
                7657031
                © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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