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A large neck is associated with a premorbid increased proinflammatory and prothrombotic status, which makes the patient more prone to progress toward an unfavorable outcome. Neck circumference is an independent predictor for mortality in our hospitalized COVID-19 patients with respiratory failure and should complement the baseline evaluation of such patients.
The SARS-CoV-2 pandemic, beginning in Wuhan (China) in December 2019, is still creating huge difficulties for the healthcare services of several countries worldwide. The clinical manifestations of the coronavirus disease 2019 (COVID-19) are heterogeneous, ranging from mild diseases to extensive pulmonary disease manifesting as acute respiratory distress syndrome which may lead to death. Despite the availability of new therapeutic options, COVID-19 mortality remains high [1], especially in hospitalized patients with pneumonia who require oxygen therapy support. Severe and fatal COVID-19 episodes are more prevalent among elderly individuals with cardiometabolic and respiratory comorbidities such as hypertension, chronic lung disease and diabetes [2][3]. Notably, most of these concomitant diseases constitute the definition of metabolic syndrome, a common metabolic disorder in the general population. In terms of COVID-19 treatment, at the present time, the most effective drug in terms of mortality reduction is dexamethasone, able to reduce the inflammatory immune-mediated pathogenic process that characterizes the second phase of the disease [4]. Heparin use at therapeutic doses did not show encouraging results, possibly for a timing issue or for the intrinsic characteristics of COVID-19 pulmonary thrombi (phlogistic platelet-rich “white thrombi’’) [5]. It has been demonstrated that hormonal and metabolic features have a significant impact on the clinical progression of COVID-19 patients. In fact, male subjects with COVID-19 have a higher mortality risk than female subjects, with 60–70% of COVID-19 associated deaths occurring in men [6]. In addition, from a metabolic point of view, it is well known that the body mass index (BMI) correlates with a worse prognosis among COVID-19 patients [7], however, BMI measurement as a prognostic tool has some limitations since it disregards the fat distribution. In fact, more than the mere BMI, is the fat distribution to reflect a dysmetabolism oriented toward metabolic syndrome. Current findings confirm that upper body fat is a good predictor of metabolic syndrome [8] with several studies demonstrating upper-body obesity to have a stronger association with cardiometabolic conditions compared to lower-body obesity. Patients with a central obesity distribution have a higher risk of hypertension, type 2 diabetes, obstructive sleep apnea syndrome, and non-alcoholic fatty liver diseases. Metabolic syndrome is a pathologic condition characterized by abdominal obesity, insulin resistance, hypertension, and hyperlipidemia. The precise global prevalence of metabolic syndrome is difficult to measure but it is estimated to be about one-quarter of the world population [9]. It is well known that metabolic syndrome is associated with an increase in pro-inflammatory cytokines (IL-6, TNF-α), markers of pro-oxidant status (OxLDL, uric acid), and prothrombotic factors (PAI-1) [10]. Moreover, C-reactive protein (CRP) strongly correlates with upper body fat [8] and neck circumference is associated with upper body fat (central body obesity) [11]. In addition, neck circumference has been shown to be strongly related to insulin resistance, early-stage atherosclerosis, diabetes, coronary heart diseases, and cardiometabolic syndrome even after adjustment for visceral adipose tissue and BMI [12]. In a previous study on 132 COVID-19 patients, we demonstrated that neck circumference measured on admission is independently and significantly associated with the progression to mechanical ventilation (adjusted OR 1.26-per 1 cm increase; 95% CI: 1.120–1.417; p < 0.001) [13]. At that time our sample was too small to investigate the relationship between neck circumference and mortality. In the present study, with a larger sample size, we aimed to assess if neck circumference measured on hospital admission correlates with the occurrence of short- and mid-term mortality among COVID-19 hospitalized patients, thus investigating its potential as a cheap and easy-to-use prognostic predictor.