ABSTRACT
Introducción: El objetivo del manuscrito es describir la vía clínica de tratamiento precoz de pacientes con infección aguda por SARS-CoV-2 y evaluar los primeros resultados de su implementación Métodos: Estudio descriptivo y retrospectivo de la implementación de una vía clínica de tratamiento en pacientes no-hospitalizados, (1 de enero al 30 de junio 2022). Elaboración de vía clínica: sistemas detección y derivación desde Atención Primaria, servicio de Urgencias, especialidades médicas y sistema de detección automatizada;evaluación clínica y administración de tratamiento en hospital de día COVID-19, y seguimiento clínico posterior. Variables explicativas: demográficas, comorbilidad, estado vacunal, vías de derivación y administración de tratamiento. Variables de resultado: hospitalización y muerte a los 30 días, toxicidad grado 2-3 relacionada con el tratamiento. Resultados: Se administró tratamiento a 262 pacientes (53,4% mujeres, mediana de edad 60 años). Criterio indicación tratamiento: inmunosupresión (68,3%) y la combinación de edad, estado vacunal y comorbilidad en el resto. El 47,3% de los pacientes recibieron remdesivir, el 35,9% nirmatrelvir/ritonavir, el 13,4% sotrovimab y el 2,4% tratamiento combinado, con una mediana de 4 días tras inicio de síntomas. El 6.1% de los pacientes precisó ingreso hospitalario, 3,8% por progresión COVID-19. Ningún paciente falleció. El 18,7% presentaron toxicidad grado 2-3: 89,8% disgeusia y sabor metálico relacionado con nirmatrelvir/ritonavir. Siete pacientes interrumpieron tratamiento por toxicidad. Conclusión: La creación e implementación de una vía clínica para pacientes no-hospitalizados con infección por SARS-CoV-2 es efectiva y permite la accesibilidad temprana y la equidad de los tratamientos actualmente disponibles.
ABSTRACT
Background: Better understanding of the association between characteristics of patients hospital-ized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management. Methods: Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1,164 patients from 20 hospitals across the United States. Disease severi-ty was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multi-variable logistic regression was performed. Findings: The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsuper-vised clustering of ordinal score over time revealed distinct disease course trajectories. Risk fac-tors associated with prolonged hospitalization or death by day 28 included age [≥] 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) hav-ing at least one symptom consistent with PASC, most commonly dyspnea (56% among symp-tomatic patients). Female sex was the only associated risk factor for PASC. Interpretation: Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19. Funding: NIH
Subject(s)
COVID-19 , Lymphopenia , Dyspnea , Respiratory InsufficiencyABSTRACT
Objective. To evaluate the effectiveness of a care pathway (Spanish acronym, COVID-A2R) through which patients with SARS-CoV-2 infection were referred by a hospital emergency department (ED) for fast-track in-person outpatient clinic care if they did not have respiratory insufficiency but were at high risk for complications and poor outcome. Methods. Retrospective cohort of patients referred to the COVID-A2R pathway after being diagnosed with COVID-19 by reverse transcription polymerase chain reaction assay in a tertiary care hospital ED between January 7 and February 17, 2021. The inclusion criteria were 1) absence of pneumonia but presence of serious comorbidity and/or elevated biomarkers of inflammation, and 2) pneumonia with or without elevated inflammatory markers but without respiratory insufficiency. The main outcome was need for an emergency department revisit with hospital admission and time from ED evaluation to hospitalization. Secondary outcomes were the number of COVID-A2R visits and the potential economic impact. Results. We included 278 patients with a median age of 57 years (57.9% men) and a median Charlson Comorbidity Index of 1. The median time since onset of symptoms was 7 days (interquartile range, 4--11 days). Pneumonia was diagnosed in 71.8%, and 64.7% required only 1 in-person visit in the COVID-A2R pathway. No revisits to the ED were needed by 87.8% (83.4%--91.1%) of the patients. Of the 34 patients who were hospitalized, 88.2% were admitted within 5 days. The COVID-A2R model potentially saved 1708 days of hospitalization. Conclusion. The fast-track ambulatory care model was effective after emergency department discharge of patients with COVID-19 without respiratory insufficiency but with clinical or laboratory indicators of risk for poor outcome. Objetivo. Evaluar la efectividad de un modelo asistencial basado en la derivación desde el servicio de urgencias hospitalarios (SUH) a una consulta presencial precoz de alta resolución (COVID-A2R), para pacientes con infección por SARS-CoV-2 sin insuficiencia respiratoria, pero con factor de riesgo de complicación/deterioro clínico. Método. Cohorte retrospectiva de pacientes remitidos por COVID-19 (RT-PCR) desde el SUH de un hospital terciario a COVID-A2R (7 de enero - 17 de febrero de 2021). Los criterios de inclusión son presencia de alta comorbilidad y elevación de biomarcadores inflamatorios en pacientes sin neumonía, o la presencia de neumonía con elevación de biomarcadores inflamatorios sin insuficiencia respiratoria. La variable de resultado principal fue el no requerimiento de revisita en el SUH con ingreso hospitalario y su distribución temporal. Los objetivos secundarios son la frecuentación en COVID-A2R y el impacto económico potencial. Resultados. Se incluyeron 278 pacientes, edad mediana de 57 años, 57,9% hombres e índice de Charlson de 1. Consultaron en el SUH tras 7 (4-11) días de clínica y un 71,8% de los casos presentaban neumonía. El 64,7% de los pacientes requirió una visita única en COVID-A2R. No se produjo una revisita a urgencias con ingreso en el 87,8% (83,4-91,1) de los pacientes. De los 34 pacientes que ingresaron, el 88,2% lo hizo en menos de 5 días. El ahorro po- tencial del modelo fue de 1.708 días de ingreso hospitalario. Conclusiones. Un modelo asistencial ambulatorio con una consulta de alta resolución tras el alta de urgencias es efec- tivo para pacientes con COVID-19 sin insuficiencia respiratoria con marcadores clínicos o analíticos de evolución desfavorable.
ABSTRACT
The B.1.1.529 (Omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in November of 2021 in South Africa and Botswana as well as in a sample of a traveler from South Africa in Hong Kong.1,2 Since then, B.1.1.529 has been detected in many countries globally. This variant seems to be more infectious than B.1.617.2 (Delta), has already caused super spreader events3 and has outcompeted Delta within weeks in several countries and metropolitan areas. B.1.1.529 hosts an unprecedented number of mutations in its spike gene and early reports have provided evidence for extensive immune escape and reduced vaccine effectiveness.2,4-6 Here, we investigated the neutralizing and binding activity of sera from convalescent, mRNA double vaccinated, mRNA boosted as well as convalescent double vaccinated and convalescent boosted individuals against wild type, B.1.351 and B.1.1.529 SARS-CoV-2 isolates. Neutralizing activity of sera from convalescent and double vaccinated participants was undetectable to very low against B.1.1.529 while neutralizing activity of sera from individuals who had been exposed to spike three or four times was maintained, albeit at strongly reduced levels. Binding to the B.1.1.529 receptor binding domain (RBD) and N-terminal domain (NTD) was reduced in convalescent not vaccinated but was mostly retained in vaccinated individuals.
Subject(s)
Coronavirus InfectionsABSTRACT
Introduction: Stroke is one of the manifestations of COVID-19 associated coagulopathy. Arterial infarcts are the most common presentation, however involvement of both arterial and venous irrigation is possible but rare. We report, what is, to our knowledge, the second case of concomitant arterial and venous brain thrombosis evidenced in magnetic resonance. Case presentation: A 62-year-old man presented with acute weakness of the left hand and lack of coordination in the left arm. Nine days earlier, he was positive for SARS-CoV-2 RT-PCR. The brain images revealed two subacute infarcts, one corresponding to the territory of the right middle cerebral artery, and the other in the right frontal cortical vein. Conclusion: The existence of both venous and arterial brain infarcts due to COVID-19 infection, has been previously reported once. Most of the cases of stroke are due to only arterial thrombosis, therefore this could be the starting point to start collecting data about simultaneous compromise in order to assess and compare outcomes, severity of the disease, among other variables.
Subject(s)
Brain Infarction , Muscle Weakness , Carotid Artery Thrombosis , COVID-19 , Infarction, Middle Cerebral Artery , Venous ThrombosisABSTRACT
The Spike protein from SARS-CoV-2 mediates docking of the virus onto cells and contributes to viral invasion. Several cellular receptors are involved in SARS-CoV-2 Spike docking at the cell surface, including ACE2 and neuropilin. The intermediate filament protein vimentin has been reported to be present at the surface of certain cells and act as a co-receptor for several viruses; furthermore, its potential involvement in interactions with Spike proteins has been proposed. Here we have explored the binding of Spike protein constructs to several cell types using low-temperature immunofluorescence approaches in live cells, to minimize internalization. Incubation of cells with tagged Spike S or Spike S1 subunit led to discrete dotted patterns at the cell surface, which showed scarce colocalization with a lipid raft marker, but consistent coincidence with ACE2. Under our conditions, vimentin immunoreactivity appeared as spots or patches unevenly distributed at the surface of diverse cell types. Remarkably, several observations including potential antibody internalization and adherence to cells of vimentin-positive structures present in the extracellular medium exposed the complexity of vimentin cell surface immunoreactivity, which requires careful assessment. Notably, overall colocalization of Spike and vimentin signals markedly varied with the cell type and the immunodetection sequence. In turn, vimentin-positive spots moderately colocalized with ACE2; however, a particular enrichment was detected at elongated structures positive for acetylated tubulin, consistent with primary cilia, which also showed Spike binding. Thus, these results suggest that vimentin-ACE2 interaction could occur at selective locations near the cell surface, including ciliated structures, which can act as platforms for SARS-CoV-2 docking.