{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,23]],"date-time":"2026-01-23T19:58:12Z","timestamp":1769198292217,"version":"3.49.0"},"reference-count":55,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2022,3,29]],"date-time":"2022-03-29T00:00:00Z","timestamp":1648512000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: COVID-19 is caused by SARS-CoV-2 infection and has reached pandemic proportions. Since then, several clinical characteristics have been associated with poor outcomes. This study aimed to describe the morbidity profile of COVID-19 deaths in Portugal. Methods: A study was performed including deaths certificated in Portugal with \u201cCOVID-19\u201d (ICD-10: U07.1 or U07.2) coded as the underlying cause of death from the National e-Death Certificates Information System between 16 March and 31 December 2020. Comorbidities were derived from ICD-10 codes using the Charlson and Elixhauser indexes. The resident Portuguese population estimates for 2020 were used. Results: The study included 6701 deaths (death rate: 65.1 deaths\/100,000 inhabitants), predominantly males (72.1). The male-to-female mortality ratio was 1.1. The male-to-female mortality rate ratio was 1.2; however, within age groups, it varied 5.0\u201311.4-fold. COVID-19 deaths in Portugal during 2020 occurred mainly in individuals aged 80 years or older, predominantly in public healthcare institutions. Uncomplicated hypertension, uncomplicated diabetes mellitus, congestive heart failure, renal failure, cardiac arrhythmias, dementia, and cerebrovascular disease were observed among COVID-19 deceased patients, with prevalences higher than 10%. A high prevalence of zero morbidities was registered using both the Elixhauser and Charlson comorbidities lists (above 40.2%). Nevertheless, high multimorbidity was also identified at the time of COVID-19 death (about 36.5%). Higher multimorbidity levels were observed in men, increasing with age up to 80 years old. Zero-morbidity prevalence and high multimorbidity prevalences varied throughout the year 2020, seemingly more elevated in the mortality waves\u2019 peaks, suggesting variation according to the degree of disease incidence at a given period. Conclusions: This study provides detailed sociodemographic and clinical information on all certificated deaths from COVID-19 in Portugal during 2020, showing complex and extreme levels of morbidity (zero-morbidity vs. high multimorbidity) dynamics during the first year of the pandemic in Portugal.<\/jats:p>","DOI":"10.3390\/jcm11071898","type":"journal-article","created":{"date-parts":[[2022,3,29]],"date-time":"2022-03-29T21:44:52Z","timestamp":1648590292000},"page":"1898","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Multimorbidity Profile of COVID-19 Deaths in Portugal during 2020"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8316-5035","authenticated-orcid":false,"given":"Paulo Jorge","family":"Nogueira","sequence":"first","affiliation":[{"name":"Instituto de Medicina Preventiva e Sa\u00fade P\u00fablica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"\u00c1rea Disciplinar Aut\u00f3noma de Bioestat\u00edstica (Laborat\u00f3rio de Biomatem\u00e1tica), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7084-8301","authenticated-orcid":false,"given":"Miguel","family":"de Ara\u00fajo Nobre","sequence":"additional","affiliation":[{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Cl\u00ednica Universit\u00e1ria de Estomatologia, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"given":"Cec\u00edlia","family":"Elias","sequence":"additional","affiliation":[{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Unidade de Sa\u00fade P\u00fablica Francisco George, Agrupamento de Centros de Sa\u00fade Lisboa Norte, Administra\u00e7\u00e3o Regional de Sa\u00fade de Lisboa e Vale do Tejo, 1500-559 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5780-2288","authenticated-orcid":false,"given":"Rodrigo","family":"Feteira-Santos","sequence":"additional","affiliation":[{"name":"Instituto de Medicina Preventiva e Sa\u00fade P\u00fablica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"\u00c1rea Disciplinar Aut\u00f3noma de Bioestat\u00edstica (Laborat\u00f3rio de Biomatem\u00e1tica), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"given":"Ant\u00f3nio C.-V.","family":"Martinho","sequence":"additional","affiliation":[{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"AIBILI\u2014Associa\u00e7\u00e3o para Investiga\u00e7\u00e3o Biom\u00e9dica em Luz e Imagem, Azinhaga Sta, Comba, Celas, 3000-548 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6906-1392","authenticated-orcid":false,"given":"Catarina","family":"Camarinha","sequence":"additional","affiliation":[{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Unidade de Epidemiologia, Instituto de Medicina Preventiva e Sa\u00fade P\u00fablica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0421-1262","authenticated-orcid":false,"given":"Leonor","family":"Bacelar-Nicolau","sequence":"additional","affiliation":[{"name":"Instituto de Medicina Preventiva e Sa\u00fade P\u00fablica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"\u00c1rea Disciplinar Aut\u00f3noma de Bioestat\u00edstica (Laborat\u00f3rio de Biomatem\u00e1tica), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"given":"Andreia Silva","family":"Costa","sequence":"additional","affiliation":[{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"CIDNUR\u2014Centro de Investiga\u00e7\u00e3o, Inova\u00e7\u00e3o e Desenvolvimento em Enfermagem de Lisboa Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1600-190 Lisbon, Portugal"},{"name":"CRC-W\u2014Cat\u00f3lica Research Centre for Psychological, Family and Social Wellbeing, Universidade Cat\u00f3lica Portuguesa, Palma de Cima, 1649-023 Lisbon, Portugal"}]},{"given":"Cristina","family":"Furtado","sequence":"additional","affiliation":[{"name":"Instituto de Medicina Preventiva e Sa\u00fade P\u00fablica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"EPI Task-Force FMUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"National Institute of Health Dr. Ricardo Jorge, Av. Padre Cruz, 1600-560 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2934-3632","authenticated-orcid":false,"given":"Liliane","family":"Morais","sequence":"additional","affiliation":[{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8177-5785","authenticated-orcid":false,"given":"Juan","family":"Rachadell","sequence":"additional","affiliation":[{"name":"Unidade de Sa\u00fade P\u00fablica, Agrupamento de Centros de Sa\u00fade Lisboa Ocidental e Oeiras, Administra\u00e7\u00e3o Regional de Sa\u00fade de Lisboa e Vale do Tejo, 2770-219 Lisbon, Portugal"}]},{"given":"M\u00e1rio Pereira","family":"Pinto","sequence":"additional","affiliation":[{"name":"Casa Civil da Presid\u00eancia da Rep\u00fablica, Presid\u00eancia da Rep\u00fablica de Portugal, 1349-022 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8034-4529","authenticated-orcid":false,"given":"Fausto","family":"Pinto","sequence":"additional","affiliation":[{"name":"Centro Cardiovascular da Universidade de Lisboa, Centro Acad\u00e9mico de Medicina de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Departamento do Cora\u00e7\u00e3o e Vasos, Centro Hospitalar Universit\u00e1rio Lisboa Norte (CHULN), EPE, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2783-0544","authenticated-orcid":false,"given":"Ant\u00f3","family":"Vaz Carneiro","sequence":"additional","affiliation":[{"name":"Instituto de Medicina Preventiva e Sa\u00fade P\u00fablica, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Ambiental, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Instituto de Sa\u00fade Baseada na Evid\u00eancia, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"},{"name":"Cochrane Portugal, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2022,3,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1038\/s41586-020-2012-7","article-title":"A pneumonia outbreak associated with a new coronavirus of probable bat origin","volume":"579","author":"Zhou","year":"2020","journal-title":"Nature"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1016\/S1473-3099(20)30120-1","article-title":"An interactive web-based dashboard to track COVID-19 in real time","volume":"20","author":"Dong","year":"2020","journal-title":"Lancet Infect. Dis."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1199","DOI":"10.1056\/NEJMoa2001316","article-title":"Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus\u2013Infected Pneumonia","volume":"382","author":"Li","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1016\/S0140-6736(20)30183-5","article-title":"Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China","volume":"395","author":"Huang","year":"2020","journal-title":"Lancet"},{"key":"ref_5","unstructured":"Instituto Nacional de Estat\u00edstica (2021, December 20). A Mortalidade em Portugal n Contexto da Pandemia COVID-19. Available online: https:\/\/www.ine.pt\/ngt_server\/attachfileu.jsp?look_parentBoui=472955720&att_display=n&att_download=y."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Harrison, S.L., Fazio-Eynullayeva, E., Lane, D.A., Underhill, P., and Lip, G.Y.H. (2020). Comorbidities associated with mortality in 31,461 adults with COVID-19 in the United States: A federated electronic medical record analysis. PLOS Med., 17.","DOI":"10.1371\/journal.pmed.1003321"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1261","DOI":"10.1097\/CM9.0000000000000824","article-title":"Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 in Wuhan, China: A retrospective study","volume":"133","author":"Deng","year":"2020","journal-title":"Chin. Med. J."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Zhang, B., Zhou, X., Qiu, Y., Song, Y., Feng, F., Feng, J.Y., Song, Q., Jia, Q., and Wang, J. (2020). Clinical characteristics of 82 cases of death from COVID-19. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0235458"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"6317","DOI":"10.1038\/s41467-020-19741-6","article-title":"Male sex identified by global COVID-19 meta-analysis as a risk factor for death and ITU admission","volume":"11","author":"Peckham","year":"2020","journal-title":"Nat. Commun."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"100630","DOI":"10.1016\/j.eclinm.2020.100630","article-title":"Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis","volume":"29","author":"Sze","year":"2020","journal-title":"EClinicalMedicine"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.ijid.2020.07.029","article-title":"Comorbidities and the risk of severe or fatal outcomes associated with coronavirus disease 2019: A systematic review and meta-analysis","volume":"99","author":"Zhou","year":"2020","journal-title":"Int. J. Infect. Dis."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J. Chronic Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1097\/00005650-199801000-00004","article-title":"Comorbidity Measures for Use with Administrative Data","volume":"36","author":"Elixhauser","year":"1998","journal-title":"Med. Care"},{"key":"ref_14","unstructured":"WHO (2011). International Statistical Classification of Diseases and Related Health Problems."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2257","DOI":"10.7150\/ijms.50007","article-title":"Prognosis models for severe and critical COVID-19 based on the Charlson and Elixhauser comorbidity indices","volume":"17","author":"Zhou","year":"2020","journal-title":"Int. J. Med. Sci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2103","DOI":"10.1016\/j.dsx.2020.10.022","article-title":"Charlson comorbidity index and a composite of poor outcomes in COVID-19 patients: A systematic review and meta-analysis","volume":"14","author":"Kuswardhani","year":"2020","journal-title":"Diabetes Metab. Syndr. Clin. Res. Rev."},{"key":"ref_17","unstructured":"World Health Organization (2020). International Guidelines for Certification and Classification (Coding) of COVID-19 as Cause of Death."},{"key":"ref_18","unstructured":"Portal do Instituto Nacional de Estat\u00edstica (2021, December 20). Popula\u00e7\u00e3o residente (No) por Local de resid\u00eancia (NUTS-2013), Sexo e Grupo et\u00e1rio; Anual. Available online: https:\/\/www.ine.pt\/xportal\/xmain?xpid=INE&xpgid=ine_indicadores&indOcorrCod=0008273&xlang=en."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1097\/MLR.0000000000000735","article-title":"Identifying Increased Risk of Readmission and In-hospital Mortality Using Hospital Administrative Data: The AHRQ Elixhauser Comorbidity Index","volume":"55","author":"Moore","year":"2017","journal-title":"Med. Care"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"626","DOI":"10.1097\/MLR.0b013e31819432e5","article-title":"A Modification of the Elixhauser Comorbidity Measures Into a Point System for Hospital Death Using Administrative Data","volume":"47","author":"Austin","year":"2009","journal-title":"Med. Care"},{"key":"ref_21","unstructured":"Ahmad, O.B., Boschi-Pinto, C., Lopez, A.D., Murray, C.J.L., Lozano, R., and Inoue, M. (2001). Age Standardization of Rates: A New WHO Standard, Citeseer."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"648","DOI":"10.21105\/joss.00648","article-title":"comorbidity: An R package for computing comorbidity scores","volume":"3","author":"Gasparini","year":"2018","journal-title":"J. Open Source Softw."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1038\/s41577-020-0348-8","article-title":"Considering how biological sex impacts immune responses and COVID-19 outcomes","volume":"20","author":"Scully","year":"2020","journal-title":"Nat. Rev. Immunol."},{"key":"ref_24","first-page":"147","article-title":"Gender differences in the utilization of health care services","volume":"49","author":"Bertakis","year":"2000","journal-title":"J. Fam. Pract."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"626","DOI":"10.1038\/nri.2016.90","article-title":"Sex differences in immune responses","volume":"16","author":"Klein","year":"2016","journal-title":"Nat. Rev. Immunol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/j.ijid.2020.04.014","article-title":"Adoption of personal protective measures by ordinary citizens during the COVID-19 outbreak in Japan","volume":"94","author":"Machida","year":"2020","journal-title":"Int. J. Infect. Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1186\/s13756-019-0500-z","article-title":"The public washroom-friend or foe? An observational study of washroom cleanliness combined with microbiological investigation of hand hygiene facilities","volume":"8","author":"Suen","year":"2019","journal-title":"Antimicrob. Resist. Infect. Control"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1044","DOI":"10.1136\/bmj.39168.496366.55","article-title":"Use of administrative data or clinical databases as predictors of risk of death in hospital: Comparison of models","volume":"334","author":"Aylin","year":"2007","journal-title":"BMJ"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1093\/eurpub\/cky098","article-title":"Defining and measuring multimorbidity: A systematic review of systematic reviews","volume":"29","author":"Johnston","year":"2019","journal-title":"Eur. J. Public Health"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1016\/0021-9681(74)90017-4","article-title":"The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus","volume":"27","author":"Kaplan","year":"1974","journal-title":"J. Chronic Dis."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1109","DOI":"10.1097\/MLR.0b013e31825f64d0","article-title":"Systematic Review of Comorbidity Indices for Administrative Data","volume":"50","author":"Sharabiani","year":"2012","journal-title":"Med. Care"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1097\/01.mlr.0000118861.56848.ee","article-title":"Comparison of the Elixhauser and Charlson\/Deyo Methods of Comorbidity Measurement in Administrative Data","volume":"42","author":"Southern","year":"2004","journal-title":"Med. Care"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1097\/MLR.0000000000000326","article-title":"A New Elixhauser-based Comorbidity Summary Measure to Predict In-Hospital Mortality","volume":"53","author":"Thompson","year":"2015","journal-title":"Med. Care"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Izcovich, A., Ragusa, M.A., Tortosa, F., Marzio, M.A.L., Agnoletti, C., Bengolea, A., Ceirano, A., Espinosa, F., Saavedra, E., and Sanguine, V. (2020). Prognostic factors for severity and mortality in patients infected with COVID-19: A systematic review. PLoS ONE, 15.","DOI":"10.1101\/2020.04.08.20056598"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Nogueira, P.J., Nobre, M.D.A., Costa, A., Ribeiro, R.M., Furtado, C., Nicolau, L.B., Camarinha, C., Lu\u00eds, M., Abrantes, R., and Carneiro, A.V. (2020). The Role of Health Preconditions on COVID-19 Deaths in Portugal: Evidence from Surveillance Data of the First 20293 Infection Cases. J. Clin. Med., 9.","DOI":"10.3390\/jcm9082368"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1875","DOI":"10.1002\/jmv.26050","article-title":"Predictors of mortality in hospitalized COVID-19 patients: A systematic review and meta-analysis","volume":"92","author":"Tian","year":"2020","journal-title":"J. Med. Virol."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Dorjee, K., Kim, H., Bonomo, E., and Dolma, R. (2020). Prevalence and predictors of death and severe disease in patients hospitalized due to COVID-19: A comprehensive systematic review and meta-analysis of 77 studies and 38,000 patients. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0243191"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e23327","DOI":"10.1097\/MD.0000000000023327","article-title":"Clinical symptoms, comorbidities and complications in severe and non-severe patients with COVID-19: A systematic review and meta-analysis without cases duplication","volume":"99","author":"Wang","year":"2020","journal-title":"Medicine"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e22439","DOI":"10.1097\/MD.0000000000022439","article-title":"Diabetes mellitus increases the risk of hospital mortality in patients with COVID-19: Systematic review with meta-analysis","volume":"99","author":"Miller","year":"2020","journal-title":"Medicine"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1186\/s12933-020-01184-4","article-title":"Diabetes and COVID-19 among hospitalized patients in Saudi Arabia: A single-centre retrospective study","volume":"19","author":"Alguwaihes","year":"2020","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2662","DOI":"10.1002\/jmv.26677","article-title":"Obesity aggravates COVID-19: An updated systematic review and meta-analysis","volume":"93","author":"Yang","year":"2021","journal-title":"J. Med. Virol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"154378","DOI":"10.1016\/j.metabol.2020.154378","article-title":"Obesity in patients with COVID-19: A systematic review and meta-analysis","volume":"113","author":"Huang","year":"2020","journal-title":"Metabolism"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"376","DOI":"10.20344\/amp.13928","article-title":"Excess Mortality Estimation During the COVID-19 Pandemic: Preliminary Data from Portugal","volume":"33","author":"Nogueira","year":"2020","journal-title":"Acta. Med. Port."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Hajek, A., Kretzler, B., and K\u00f6nig, H.-H. (2020). Multimorbidity, Loneliness, and Social Isolation. A Systematic Review. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17228688"},{"key":"ref_45","first-page":"e166","article-title":"Multimorbidity patterns among COVID-19 deaths: Proposal for the construction of etiological models","volume":"44","author":"Idrovo","year":"2020","journal-title":"Rev. Panam. Salud P\u00fablica"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1111\/jrh.12476","article-title":"Spatial Disparities in Coronavirus Incidence and Mortality in the United States: An Ecological Analysis as of May 2020","volume":"36","author":"Zhang","year":"2020","journal-title":"J. Rural Health"},{"key":"ref_47","unstructured":"Peixoto, V.R., Vieira, A., Aguiar, P., Sousa, P., Carvalho, C., Thomas, D., Abrantes, A., and Nunes, C. (2020). COVID-19: Determinants of Hospitalization, ICU and Death among 20,293 reported cases in Portugal. medRxiv."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"465","DOI":"10.15585\/mmwr.mm6915e4","article-title":"Geographic Differences in COVID-19 Cases, Deaths, and Incidence\u2014United States, February 12\u2013April 7, 2020","volume":"69","author":"Bialek","year":"2020","journal-title":"MMWR. Morb. Mortal. Wkly. Rep."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1038\/s41586-021-03426-1","article-title":"Increased mortality in community-tested cases of SARS-CoV-2 lineage B.1.1.7","volume":"593","author":"Davies","year":"2021","journal-title":"Nature"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"191","DOI":"10.2188\/jea.JE20150010","article-title":"Accuracy of Death Certificates and Assessment of Factors for Misclassification of Underlying Cause of Death","volume":"26","author":"Mieno","year":"2016","journal-title":"J. Epidemiol."},{"key":"ref_51","first-page":"137","article-title":"Tecnologias de informa\u00e7\u00e3o e comunica\u00e7\u00e3o no registro de \u00f3bitos em Portugal","volume":"9","author":"Nunes","year":"2017","journal-title":"J. Health Inform."},{"key":"ref_52","first-page":"48","article-title":"Improving the mortality information system in Portugal","volume":"22","author":"Anderson","year":"2016","journal-title":"Eurohealth"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1215\/23289252-2399740","article-title":"International Statistical Classification of Diseases and Related Health Problems","volume":"1","author":"Eisfeld","year":"2014","journal-title":"TSQ Transgender Stud. Q."},{"key":"ref_54","first-page":"1","article-title":"Mortality Information System in Portugal: Transition to e-death certification","volume":"22","author":"Pinto","year":"2016","journal-title":"Eurohealth"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"74","DOI":"10.3121\/cmr.2015.1276","article-title":"Principles and Pitfalls: A Guide to Death Certification","volume":"13","author":"Brooks","year":"2015","journal-title":"Clin. Med. Res."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/7\/1898\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T22:45:45Z","timestamp":1760136345000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/7\/1898"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,3,29]]},"references-count":55,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2022,4]]}},"alternative-id":["jcm11071898"],"URL":"https:\/\/doi.org\/10.3390\/jcm11071898","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,3,29]]}}}