ABSTRACT
Background: Neutrophil serine proteases (NSPs) are involved in the pathogenesis of COVID19 and are increased in severe and fatal infection. We investigated whether treatment with Brensocatib, an inhibitor of dipeptidyl peptidase-1, an enzyme responsible for the activation of NSPs, would improve outcomes in hospitalized patients with COVID19. Method(s): In a randomized, double-blind, placebo-controlled trial, 406 hospitalized patients with COVID19 with at least one risk factor for severe disease were randomized 1:1 to once-daily Brensocatib 25mg (n=192) or placebo (n=214) for 28 days. Primary outcome was the 7-point World Health Organisation Clinical Status scale at day 29. Secondary outcomes included time to clinical improvement, national early warning score, new oxygen and ventilation use, neutrophil elastase activity in blood and mortality. Finding(s): Brensocatib treatment was associated with worse clinical status at day 29 (adjusted odds ratio 0 72, 95%CI 0 57-0 92) compared to placebo. The adjusted hazard ratio (aHR) for time to clinical improvement was 0 87 (95%CI 0 76-1 00) and time to hospital discharge was 0 98 (95%CI 0 84-1 13). During the 28-day follow-up period, 23 (11%) and 29 (15%) patients died in the placebo and Brensocatib treated groups respectively). Oxygen and new ventilation use were greater in the Brensocatib treated patients. Neutrophil elastase activity in blood was significantly reduced in the Brensocatib group from baseline to day 29. Prespecified subgroup analyses of the primary outcome supported the primary results.
ABSTRACT
Introduction: COVID19 can cause neutrophilic inflammation and reaction oxygen species (ROS) production, leading to acute lung injury and mortality. AMPK is a key regulator of cellular energy with profound effects on neutrophil function. This study aims to investigate the role of AMPK activity in neutrophils during COVID-19 and pneumonia caused by pathogens other than SARS-CoV-2. Method(s): Patients hospitalised due to pneumonia or COVID-19 were recruited from Ninewells Hospital (Dundee, UK). Blood was sampled at day 1, 8, and 15. ROS production, phospho-AMPK (pAMPK), and NQO1 were stained in neutrophils, and then analysed by flow cytometry. The endogenous AMPK inhibitor, resistin, was quantified by ELISA, in serum (day 1, 8, 15). WHO clinical scale and CURB65 score were utilised to define severity. Result(s): 133 patients were enrolled (mean age 63.6 years). Resistin was not different between pneumonia and COVID-19 on day1. However, day 1 resistin was higher in severe disease defined by CURB65 Score (p=0.0220) and WHO score (p=0.0184). Resistin reduced over time at day 1 (mean 63.1pg/mL;n=121) to day 15 (mean 59.5pg/mL;n=66)(p=0.0002). Zymosan stimulation significantly increases neutrophil ROS production (p<0.0001), and significantly decreases NQO1 (p<0.0001), but caused no changes with pAMPK. There were no changes in these markers over time. pAMPK significantly correlated with NQO1 in unstimulated neutrophils (p=0.0388), but not when stimulated with zymosan. There were no associations between resistin and pAMPK, and no difference in these markers between pneumonia and COVID-19 groups. Conclusion(s): Our study suggests resistin as a marker of severity and disease course in COVID-19, independent of neutrophil AMPK signalling.
ABSTRACT
Introduction: SARS-CoV-2 infection has profound effects on endothelial and immune cell function and coagulation, and better understanding of these events in COVID-19 would allow for targeted cardiovascular treatment and followup. Method(s): Longitudinal observational study of patients with PCR-confirmed SARS-CoV-2 infection admitted to hospital at two UK sites. Patients were enrolled within 96 hours of admission, with sampling up to day 29. RNAstabilised whole blood was processed for mRNA sequencing. Gene expression levels were compared between patients who did and did not suffer a major cardiac event (MACE) from admission to 1-year post-hospitalization. Result(s): At day 1, in acute COVID-19, no differences in gene expression were observed between those with (n=23) and without (n=140) a MACE. However, 93 significant differentially expressed genes (DEGs;adjusted pvalue<0.05;Wald test with Benjamini-Hochberg correction) were identified at day 29 between patients who suffered a MACE (n=16) or not (n=85) post-hospitalization. Neutrophil elastase (ELANE), tissue factor pathways inhibitor (TFPI) and integrin subunit alpha-2 (ITGA2B) were significantly elevated in patients who suffered a MACE. Significantly enriched pathways associated with cardiovascular events included type I interferon signalling and neutrophil chemotaxis. Conclusion(s): COVID-19 patients who experienced a MACE demonstrated significant changes in peripheral blood transcriptome 29 days after hospital admission. Significant DEGs were related to neutrophil activity, coagulation and interferon signalling, suggesting a relationship between these pathways and increased cardiovascular risk.
ABSTRACT
Introduction and ObjectivesNeutrophils are increasingly recognised for a role in acute COVID19, contributing to hyperinflammatory responses, immunothrombosis and tissue damage. However, less is known about the cellular changes occurring within neutrophils in acute disease, as well as neutrophil function in patients recovering from COVID19. Mass spectrometry-based proteomics of neutrophils from hospitalised COVID19 patients sampled longitudinally was utilised to characterise these cells in both acute and long COVID19 (i.e. symptoms for ≥4 weeks).MethodsProspective observational study of hospitalised patients with PCR-confirmed SARS-CoV-2 infection (May 2020–December 2020). Patients were enrolled within 96 hours of admission, with longitudinal sampling up to day 29. Control groups comprised hospitalised patients with non-COVID19 acute respiratory infection and age-matched non-infected controls. Neutrophils isolated from peripheral blood were processed for mass spectrometry. COVID19 severity was defined using the WHO 7-point ordinal scale.Results84 COVID19 patients were included (mean age±SD 65.5±14.6 years;52.4% male), 91 non-COVID19 respiratory infection patients (age 65.7±16.7 years;49.5% male) and 42 non-infected controls (age 58.5±17.9;40% male). 1,748 proteins were significantly different (q-value≤0.05) in COVID19 neutrophils compared to those of non-infected controls. Major differences included a robust interferon response at baseline, with markers of neutrophil immaturity (CD10, CD71), increased neutrophil activation (CD64), and changes in metabolism which associated with COVID19 disease severity. Delayed recovery (WHO score 2–3) at day 29 was associated with significant changes in 1,107 proteins compared to the control population. Features of non-recovery included significantly reduced abundance of migratory receptors (e.g. C3AR1, LTB4R), integrins (CD11b, CD18), inhibitory molecules (e.g. SHP-1, SHIP-1) and indications of increased activation (CD64). Overall, ficolin and specific granule content was decreased in COVID19 patient neutrophils at day 29 compared with controls, however, comparing those who had recovered and those who had not, granule content was found to be significantly lower in the non-recovery group.ConclusionNeutrophils undergo significant changes in acute COVID19 associated with disease severity. Neutrophil proteomics revealed that these cells may have an ongoing role in non-recovered patients, including profiles associated with increased potential for neutrophil activation and reduced migratory capacity, highlighting neutrophils as potential therapeutic targets in long COVID19.
ABSTRACT
S55 Figure 1Transmission Electron Micrographs of ciliated epithelial cells 3months- 1 year post-COVID. Red circles represent microtubular subunits assembling during ciliogenesis, the white arrow shows short regenerating cilia. Yellow boxes surround intracytoplasmic cilia seen in 90% post COVID cases and suggestive of a defect in ciliogenesis[Figure omitted. See PDF]ConclusionEpithelial disruption and defects in epithelial regeneration persist for up to 1 year post infection with SARS-CoV-2, irrespective of initial illness severity. Persisting inflammation, or a failure of repair, are possible pathological processes for further exploration.
ABSTRACT
IntroductionCOVID-19 is reported to cause profound systemic inflammation. Anti-inflammatory treatments such as corticosteroids and anti-IL-6 receptor monoclonal antibodies reduce mortality. Identifying inflammatory biomarkers associated with increased morbidity and mortality may allow both prediction of outcomes and identification of further therapeutic targets.MethodsA prospective observational study of patients with PCR-confirmed SARS-CoV-2 admitted to a single centre in Dundee, UK. Patients were enrolled within 96 hours of hospital admission. 45 inflammatory biomarkers were measured in serum using the Olink Target48 proteomic-based biomarker panel. Additional markers were measured by ELISA/immunoassay and enzyme activity assays. Severe disease was defined as the requirement for non-invasive or mechanical ventilation or death within 28 days of admission. Discrimination between groups was evaluated using the area under the receiver operator characteristic curve (AUC).Results176 patients were included (mean age 64.9 years, SD 13.6), 101 were male (57.4%). 56 patients developed severe disease (31.8%), mortality was 16.5%. Using ROC analysis, the strongest predictors of severity (p<0.0001) were CCL7/MCP3 (AUC 0.78 95%CI 0.70–0.85), IL6 (0.73 95%CI 0.66–0.81), IL15 (0.73 95%CI 0.65–0.81), CXCL10/IP10 (0.73 95%CI 0.65–0.81). Further significant predictors of severity included CXCL11, IL10, CCL2/MCP1 and CSF2/GM-CSF. Predictors of mortality were CXCL10 (0.78 95%CI 0.69–0.86), IL6 (0.76 95%CI 0.67–0.85), IL15 (0.75 95%CI 0.66–0.84), IL10 (0.73 95%CI 0.64–0.82). Further significant predictors of mortality were CXCL9 and CCL7.ConclusionMultiple circulating biomarkers were identified which predicted disease severity and mortality in COVID19, indicating clinical value in measurement upon hospital admission to highlight high-risk patients. Associated biological processes for these proteins included anti-viral and interferon responses and immune cell chemotaxis. In particular, CCL7 and CXCL10, the strongest predictors of severity and mortality in this dataset, are key players in the cytokine storm and immune cell recruitment linked with COVID19. These chemokines are not currently therapeutic targets, highlighting key avenues for further clinical research.
ABSTRACT
IntroductionCOVID-19 has been reported to induce a ‘cytokine storm’ distinct from other acute respiratory tract infections (LRTIs). Understanding the similarities and differences in inflammatory profiles between SARS-CoV-2 infection and other respiratory infections may aid diagnosis, as well as the potential to repurpose therapies such as steroids and anti-IL-6 receptor antagonists for other respiratory infections.MethodsA prospective observational study of patients in 3 groups 1) PCR confirmed SARS-CoV-2 infection, 2) community-acquired pneumonia (CAP) without SARS-CoV-2, and 3) controls hospitalized for reasons other than infection. Patients were enrolled from a single centre in Dundee, UK. Patients were enrolled within 96 hours of hospital admission. 45 inflammatory biomarkers were measured in blood using the Olink target proteomic based biomarker panel. Additional markers were measured by ELISA/immunoassay and enzyme activity assay as appropriate. Discrimination between groups was evaluated using the area under the receiver operator characteristic curve (AUC).Results294 patients were included (COVID-19 n=176, CAP n=76, controls n=42), mean age 64 (SD±15.2) and 150 subjects were male (51.0%). Using ROC analysis the most discriminating biomarkers for COVID-19 compared to CAP were CXCL-10 (AUC 0.84 95%CI 0.78–0.90 p<0.001), CCL-8 (0.87 95%CI 0.82–0.92, p<0.001), CCL-7 (0.84 95%CI 0.78–0.89, p<0.001), CXCL-11 (0.80 95%CI 0.73–0.88, p<0.001). Further biomarkers included IL-18, IL-7, IL-10 and IL-33. The most discriminating biomarkers for COVID-19 compared to controls were CXCL-10 (0.89 95%CI 0.85–0.93, p<0.001, CCL-7 (0.88 95%CI 0.83–0.92, p<0.001), CCL-8 (0.87 95%CI 0.82–0.92, p<0.001). Further biomarkers included IL-10, CXCL-11 and IL-18. IL-4 was significantly lower in COVID-19 patients compared to controls (0.27 95%CI 0.16–0.38, p<0.001). No significant difference in IL-6 was seen between COVID-19 and CAP (median 21.9pg/ml vs 19.8pg/ml,p=0.59).ConclusionDifferential markers of inflammation were identified between COVID-19, CAP and control samples, indicating distinct immunological pathways. The identification of a similar IL-6 signature between COVID-19 and CAP indicates that IL-6 targeting therapies currently being used to treat COIVD-19 may also be beneficial in the treatment of CAP.
ABSTRACT
Introduction: Sleep problems remain problematically prevalent among U.S. service members. In 2015 over 60% of sampled service members reported getting less than 7 hours of sleep per night, 31.4% getting 5 hours or less, and nearly 50% reported subthreshold insomnia symptoms on the Pittsburgh Sleep Quality Index. Ongoing COVID-19 service delivery restrictions necessitate a rapid shift to virtual health solutions and illuminate barriers to the delivery of sleep interventions. This process improvement pilot was a proof-of-concept during uncertain times. Methods: From September to January 2020, 10 weekly 1-time, 60-min virtual sleep classes were held over Microsoft Teams. Interventions were consistent with Motivational Interviewing and Brief Behavioral Treatment for Insomnia. Participants completed the STOP BANG and Insomnia Severity Index (ISI) before each class, and accomplished the ISI again at a 2-week contact during which they rated progress toward problem resolution and were offered additional clinical services as-needed. Results: Forty-six participants attended the class. 67% responded to the post-class survey. 74% responded to the two-week follow-up. A majority (84%) indicated either agreement or strong agreement with the statement 'I plan to CHANGE a behavior or TRY an intervention I learned to better my sleep', and many proceeded to establish a more consistent sleep schedule (n=14;45%), remove electronics from the bedroom (n=13;42%), and/or go to bed only when sleepy (n=11;35%). 84% would recommend this class to others with similar concerns. Scaled from 1 ('no change') to 10 ('full resolution'), participants reported having derived modest benefit from the intervention (M = 4.1, SD=1.7). Eleven (35%) denied need for additional sleep-related services, and 84% expressed intent to recommend the class to others with similar concerns. Conclusion: Results suggest a military population is receptive to a 1-time, virtual sleep class consistent with social distancing strictures. This service provided patients rapid access to care while contemporaneously reducing demand for time-intensive one-to-one appointments. As hypothesized, receipt of the intervention was associated with intention to modify sleep-relevant behavior, and with meaningful progress toward resolution of sleep difficulty as assessed at 2-week follow-up. Broadly disseminated, this intervention could introduce an internetbased, stepped-care approach to management of sleep insufficiency across the DoD.
ABSTRACT
RATIONALE: Healthcare workers (HCW) are believed to be at increased risk of SARS-CoV-2 infection. The extent of that increased risk compared to the general population and the groups most at risk have not been extensively studied. It is also not known to what extent the natural production of antibodies to SARS-CoV-2 is protective against re-infection. Methods: A prospective observational study of health and social care workers in NHS Tayside (Scotland, UK) from May to September 2020. The Siemens SARS-CoV-2 total antibody assay was used to establish seroprevalence in this cohort. Patients provided clinical information including demographics and workplace. Controls, matched for age and sex to the general Tayside population, were studied for comparison. New laboratory confirmed infections post September 2020 were recorded to determine if the presence of SARS-CoV-2 antibodies protect against re-infection. Results: A total of 2063 health and social care workers were recruited for this study. The participants were predominantly female (81.7%) and 95.5% were white. 300 healthcare workers had a positive antibody test (14.5%). 11 out of 231 control sera tested positive (4.8%). Healthcare workers therefore had an increased likelihood of a positive test (Odds ratio 3.4 95% CI 1.85-6.16, p<0.0001). Dentists, healthcare assistants and porters were the job roles most likely to test positive. Those working in front-line roles with COVID-19 patients were more likely to test positive (17.4% vs. 13.4%, p=0.02). 97.3% of patients who had previously tested positive for SARSCoV-2 by RT-PCR had positive antibodies, compared to 10.9% of individuals with a symptomatic illness who had tested negative. 18.7% of HCW had an asymptomatic infection. Anosmia was the symptom most associated with the presence of detectable antibodies. There were 38 new infections with SARS-CoV-2 in HCW who were previously antibody negative and 1 symptomatic RT-PCR positive re-infection in a HCW who had detectable antibodies 76 days prior to re-infection. The presence of antibodies was 85% protective against re-infection with SARS-CoV-2 (HR 0.15, 95% CI 0.06 to 0.35, p=0.03). Conclusion: In this study, healthcare workers were three times more likely to test positive for SARS-CoV-2 than the general population. Almost all of the infected individuals developed an antibody response and this was 85% effective in protecting against reinfection with SARS-CoV-2.