Dipeptidyl Peptidase-1 Inhibition in Patients Hospitalized with COVID-19: a Multicentre Randomized Double-Blind Placebo Controlled Trial

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.

Altered neutrophil proteomes in COVID19 patients 29-days post hospital admission are associated with delayed recovery: results from the PREDICT-COVID19 study

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.

The impact of disposable face masks on dynamic lung function in healthy young adults

PURPOSE/HYPOTHESIS: The purpose of this investigation was to measure the effects of wearing a disposable mask on dynamic lung function in young, healthy adults. NUMBER OF SUBJECTS: Twenty subjects (10 Males and 10 Females) participated in this investigation. MATERIALS AND METHODS: This IRB-exempt investigation involved subjects being measured for height and weight prior to participation in dynamic pulmonary function testing. Subjects participated in three unmasked (UM) and three masked (M) seated trials using a nose clip and calibrated Microloop Spirometer (Accuracy = ±.03%). Sets of trials were randomized with 60-sec rest between each seated trial and 60-sec rest between sets of trials. Subjects forcefully exhaled through a Vyaire filter for all tests and through a breathable facemask made from non-woven polyester and polypropylene with elastic ear loops for the M trials. Three trials for Forced Expiratory Volume in 1-sec (FEV1), Forced Vital Capacity (FVC), FEV1/FVC ratio, and Peak Expiratory Flow Rate (PEF) were measured on the spirometer and averaged for statistical analysis. Trials that did not meet ATS guidelines were repeated. Statistical Analysis: Paired t-tests (SPSS26) were used to test for differences between M vs. UM breathing conditions (mean of three trials) and significance was set at P ≤ 0.0125 using Bonferroni correction. Descriptive statistics (mean ± standard deviation) for dependent variables are presented below. RESULTS: Subjects were 23.35 ± 1.55 years of age, 68.5 ± 4.58 inches tall, and weighed 166.38 ± 35.36 lbs. All dynamic pulmonary function tests were significantly reduced during the M vs. the UM condition. Mean UM and M FEV1 values were 3.76 ±.972 L/sec and 2.53 ±.758 L/sec, respectively (t(19) = 8.33, P≤ .001). Mean UM and M FVC values were 4.37 ± 1.190 and 3.17 ±.904 Liters, respectively (t(19) =6.58, P≤ .001). Mean UM and M PEF values were 6.30 ± 2.06 L/sec and 3.26 ± 1.21 L/sec, respectively (t(19) = 9.34, P≤ .001). FEV1/FVC UM and M values were 86.78% ± 6.26 and 79.70% ± 6.60, respectively (t(19) = 5.11, P≤ .001). Wearing a mask caused a 32.7%, 33.0%, 48.3% and 8.16% reduction in FEV1, FVC, PEFR, and FEV1/FVC condition, respectively. CONCLUSIONS: Breathable ear loop disposable facemasks significantly reduced FVC, FEV1, FEV1/FVC and PEF in young adults. CLINICAL RELEVANCE: Children and adults throughout the world have been strongly encouraged/required to wear various types of facemasks throughout the COVID-19 epidemic. In the current study, Mask use drove FEV1/FVC towards the Postbronchodilator GOLD criteria for obstructive disease in this young healthy population. One can hypothesize M use during exercise or work would cause a reduction in lung function in healthy subjects, the elderly and in those with cardiorespiratory pathology, negatively affecting their ADLs, functional fitness, and metabolic energy reserve.

Assessment of sleep disturbances in children and adolescents with inflammatory bowel disease

Background: Poor sleep has been well described in the adult inflammatory bowel disease (IBD) population. Few studies in the pediatric population have demonstrated a similar relationship. The aim of this study was to assess the prevalence of sleep disturbances and sleep-related daytime impairments in children and adolescents with IBD. Methods: This pilot, prospective cross-sectional study included pediatric IBD patients seen in the GI clinic or infusion center at The American Family Children's Hospital in Madison, Wisconsin between February and April of 2021. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Sleep Disturbance-Short Form and Pediatric Sleep-Related Impairment-Short Form questionnaires at the time of their visits. The questionnaires assessed difficulties with sleep at night, and daytime symptoms associated with poor sleep. The disease activity was scored using the Abbreviated Pediatric Crohn's Disease Index (PCDAI) for Crohn's Disease and the Pediatric Ulcerative Colitis Activity Index (PUCAI) for Ulcerative and Indeterminate Colitis. Demographics, disease-related information, and laboratory data within the past 6 months from time of the patient visit were acquired from medical charts. Iron deficiency was determined by ferritin <30 ng/mL or iron saturation <20% with a normal CRP or ferritin <100 ng/mL with an elevated CRP. Vitamin D deficiency was determined by 25-hydroxy-vitamin D ≤30 ng/mL. All data was analyzed using Fisher's exact test and a p-value <0.05 was used to define statistical significance. Results: Forty-four patients (mean age 14.7, SD 2.8) with IBD (68.2% with Crohn's Disease, 25.0% with Ulcerative Colitis, 6.8% with Indeterminate Colitis) were enrolled. Of those with Crohn's Disease, 73.3% had inactive disease and 26.6% had active disease based on PCDAI score. For those with Ulcerative and Indeterminate Colitis, 57.1% were in remission and 42.8% had active disease based on PUCAI scores. Of all patients, 29.6% had some degree of sleep disturbance and 50.0% had sleep-related daytime impairments. Additionally, 13.6% of patients were currently taking a sleep medication and 20.5% had been on oral steroids within the last 3 months. Among the patients, 44.2% had iron deficiency and 61.9% had vitamin D deficiency. Patients with active disease reported more sleep disturbances (43% vs 23%, p=0.2878) and sleep-related daytime impairments (71% vs 40%, p=0.0520), however the results were not statistically significant. Patients with vitamin D deficiency reported fewer sleep disturbances than those with no vitamin D deficiency, which was statistically significant (19% vs 50%, p=0.0472). There was no significant difference in sleep-related daytime impairments between those groups (38% vs 69%, p=0.1109). Statistical analysis showed that age, iron deficiency, and current/recent use of oral steroids were not significantly correlated with sleep disturbances or sleep-related daytime impairments. Conclusions: Despite the previously reported correlation between IBD and sleep, our pilot study does not demonstrate a strong correlation between sleep disturbances and disease activity. However, this relationship may be shown among a larger patient population than seen in this study. There was a higher prevalence of sleep-related daytime impairments rather than sleep disturbances among all enrolled IBD patients. This could reflect the overlap between sleepiness and fatigue as these are difficult to distinguish. In addition, there are numerous cofactors that can cause sleep problems in pediatric patients. These include variables such as age, oral steroids, iron deficiency, and vitamin D deficiency. To our surprise, our patients with vitamin D deficiency reported better sleep compared to patients with normal vitamin D levels;however, vitamin D levels were obtained anywhere up to 6 months prior to sleep questionnaire completion. Sample size of the study was limited due to a 2-month data collection period, and the ongoing COVID-19 pandemic restricting in-person visi s. Other limitations include the accurateness of self-reported answers on the sleep questionnaires and the time variability between laboratory values and administration of the sleep questionnaires. Future research may be helpful to further study sleep issues in pediatric IBD patients.

Persistent changes to the nasal ciliated epithelium following SARS-CoV2 infection: a longitudinal cohort analysis from FOLLOW-COVID

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.

Inflammatory biomarkers predict clinical outcomes in patients with COVID-19 infection: results from the PREDICT-COVID19 study

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.

Comparison of inflammatory profiles between COVID-19 and other acute lower respiratory tract infections: Results from the PREDICT-COVID19 study

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.

A multi-professional education and Improvement process to guide clinical practice in the developing management of covid-19: The Trainee experience

Introduction and Objectives On March 1st 2020 the World Health Organisation dashboard had recorded 1 897 cases of COVID-19, rising to 75 008 by April 1st 2020. In this time, there were rapidly emerging changes in clinical knowledge and management, challenging the work of hospital teams caring for these patients. This project specifically aimed to rapidly bring together cross-speciality medical trainees in teams to develop a distanced weekly education update to help manage this 'infodemic', including real-time audit and quality improvement projects, local case reports, and a virtual journal club. Method Initial opportunities were created for trainees to join projects including: Rapid follow up of local admissions examining demographics and clinical outcomes;anti-microbial audit;bi-weekly oxygen usage audit, and thrombosis prophylaxis. These were carried out in a quality improvement style with education and re-evaluation. Cases and journal articles were selected for educational interest. A weekly update was sent online to those working within the COVID-19 inpatient departments. There was input from over 35 individuals. Results The overall data collection ran for 7 weeks, from March 13th to May 1st, rapidly assessing 874 patient presentations and tracking the progress of 329 COVID-19 positive patients. 42 patients were admitted to level 2 care, with positive outcomes similar to national data associating with shorter lengths of stay, female gender, younger age, and lower peak CRP. An antimicrobial audit on 2 occasions found 100% adherence to local guidance. Prevalence of antimicrobial use did not differ from a concurrent audit in non covid wards (31%). Oxygen usage work showed the majority of our patients had stepwise improvement in adherence to saturation targets by week 5, in keeping with NHS England guideline of 92-96%. The thrombosis prophylaxis project found an improvement in adherence from 88% to 100% as evidence emerged of a possible increased risk of pulmonary vascular complications. A total of 5 cases of complex COVID-19 were presented during this period. Outcomes This cross-department education process allowed for multiple trainee-led projects and presentations to guide local education, and ensured that our clinical practices were reviewed and in line with evolving national guidance during a pandemic.

Effects of COVID-19 on the 2-week-wait dermatology services at a regional centre between 2019 and 2020

The COVID-19 pandemic has led to significant challenges within dermatology services. We report the impact of COVID-19 on our 'two-week-wait' (TWW) skin cancer service, comparing January-April 2019 to January-April 2020 in a tertiary setting. Specifically, we looked at the total number of TWW referrals seen over these periods, conversion rate and the types of skin cancer diagnosed. Conversion rate is defined as the percentage of suspected skin cancer referrals that are confirmed as malignancy (excluding basal cell carcinoma) on histology. Between January and April 2019, we received 1818 referrals. Within the same period in 2020, we reviewed 1444 cases. This represents a 20.5% (n = 374) reduction. Stratifying by months, we reviewed 27.0% (n = 88) more patients in January and 6.1% (n = 27) in February 2020 vs. 2019. However, we observed a 19.2% (n = 102) and 74.8% (n = 387) reduction in TWW referrals for March and April 2020, respectively, compared with the previous year. These months coincided with the peak of the COVID-19 pandemic in the U.K. Conversion rate across the 4-month period in 2019 and 2020 are in line with the national data (3-12%), ranging from 3.6% to 6.9%, with highest rate recorded in April 2020. The average conversion rate for the first quarter of 2020 was higher than 2019;5.61% vs. 4.1% (P = 0.07). Squamous cell carcinoma (SCC) and malignant melanoma (MM) were the most common skin cancer types. There was a noticeable decrease in the number of cases diagnosed in 2020. We confirmed 89 SCC and 31 MM cases in 2019 vs. 38 SCC and 14 MM cases in 2020, corresponding to a 57.3% and 54.8% reduction, respectively. Our data clearly show a significant reduction in the number of TWW referrals, treated cases and subsequently cancer diagnosis over the COVID-19 period. This is likely due to the decrease in primary care referrals coupled with a smaller number of patients seeking assessment for fear of contracting COVID-19. Furthermore, the restructuring of the dermatology department during the pandemic led to reduced surgical activity and therefore fewer cases treated. The higher mean conversion rate in 2020, although trending towards significance, may not be representative as the pandemic is still ongoing. More data will become available to cover various phases, including early restoration period in due course. This is an important first step to understand how COVID-19 has affected dermatology services in the initial phase and will aid in future planning should a second wave occur.