Monitoring the newly infected cases of COVID-19 data weekly: A Survival Data Analysis (SDA) perspective

This paper attempts to fit the best survival model distribution for the Malaysian COVID-19 new infections experience of Wave I/II and Wave III using the well-known Survival Data Analysis (SDA) procedures. The purpose of fitting such models is to reduce the complexity and frequency of the COVID-19 new infections data into a single measure of scale and shape parameters to enable monitoring of weekly trends, undertake short term forecasts and estimate duration when the virality will be contained. The analysis showed a Weibull distribution is the best statistical fit for Malaysia’s new infections COVID-19 data. The estimates of scale and shape parameters for Wave I/II was 0.05901 and 2.48956 and for Wave III was 0.06463 and 2.5693, respectively. Much higher hazard force in Wave III is due to weaker control in the implementation of cordon sanitaire measures imposed in containing the virality spread. Based on the survival function the short-term forecasts showed that the number of new infections projected to decline from 23,282 cases in 28th week to 22,017 cases in 31st week. Similarly, based on the cumulative hazard function the duration estimated for containing the virality completely projected to stretch over another 19.6 weeks under the prevailing conditions. © 2021 – IOS Press. All rights reserved.

Mechanistic Insights into a Rare Mutation in Nacad as a Possible Cause of Covid Orchitis

Objective: Aiming to uncover causal mechanisms of COVID-19 sequela outside of pulmonary symptomology, a recent study from our group identified a variant of the NACAD protein (120bp coding sequence deletion) associated with COVID-19 orchitis, a risk factor for male infertility. Interestingly, these patients had decreased ACE2 serum levels. NACAD is proposed to prevent inappropriate targeting of non-secreted peptides to the endoplasmic reticulum. We hypothesized that a defect in NACAD function/processing will decrease ACE2 serum levels by disrupting extracellular transport and endoplasmic reticulum interaction. We explored whether intracellular levels of ACE levels were altered and if cell membrane protein deposition was increased, which may result in more severe effects to SARS-CoV-2 infection. Material(s) and Method(s): We obtained testis biopsies from men undergoing sperm retrieval for infertility. After siRNA NACAD knockdown, we analyzed total ACE2 expression using Western blot and qPCR as well as immunofluorescence/H&E staining for co-localization (with NACAD). Membrane-anchored ACE2 (mACE2) levels were quantified using immunostaining and flowcytometry while secreted ACE2 (sACE2) was analyzed by ELISA and Western blot. Result(s): NACAD and ACE2 co-localize in both the Leydig and germ cells. When NACAD is knocked down, primary testes cells show 80% decreased mRNA and 50% total protein levels of ACE2. The secreted ACE2 was also reduced by nearly 50%. However, when we specifically measured the level of mACE2 on the cell surface, we found that the knockdown of NACAD did not lead to reduction. Conclusion(s): NACAD likely specifically affects the level of sACE2, which is speculated to act as a protection factor by retaining the virus in serum and reducing cellular entry. While the exact reason for the differential effects of NACAD on mACE2 and sACE2 remain unclear, our data is consistent to other studies, which found a reduction of total ACE2 expression and sACE2 in patients is coupled with worse outcomes in COVID-19. We hope that establishing a relationship between NACAD and ACE2 expression will prove useful not only to elucidate why some men with COVID develop orchitis but, ultimately, why some men develop multiorgan failure with COVID infection whereas most do not. Impact Statement: We expect that men with a history of orchitis and an increased level of ACE2 receptors will present with a higher and prolonged risk of impaired semen parameters. By identifying the impact of COVID-19 infection on male fertility, we can determine whether recommendations are warranted for sperm cryopreservation for men at high risk of contracting the infection, such as healthcare workers. Copyright © 2022

IMPACT OF SARS-COV-2 PANDEMIC ON THE DIAGNOSIS AND SURGICAL INTERVENTION OF COMMON UROLOGICAL CONDITIONS: RESULTS FROM A MULTI-INSTITUTIONAL DATABASE FROM THE UNITED STATES

INTRODUCTION AND OBJECTIVE: The SARS-CoV-2 (COVID) pandemic threatened access to healthcare, raising concerns that patients were going underdiagnosed and undertreated. The aim of our study was to understand the impact of the COVID pandemic on diagnosis and surgical management of common urological conditions. METHODS: Using a large multi-center electronic health record network (TRINETx) consisting of 46 healthcare organizations, we conducted an epidemiological study investigating the number of patients newly diagnosed with common urological conditions and those undergoing urologic surgeries at yearly intervals from March 1st, 2016 to March 1st, 2021. Relevant international classification of diseases (ICD) codes used to identify urologic conditions are elaborated on in Table 1. Current procedural terminology (CPT) codes used to identify surgeries are detailed in Figure 1. We then determined the percentage of newly diagnosed patients who underwent surgery for each specific year. RESULTS: We saw a decrease in number of all urologic surgeries being performed during the initial year of the pandemic (Figure 1). From March 2020-2021, there was a >20% decrease in surgical case load for benign prostatic hyperplasia procedures (-29.5%), prostate biopsies (-30.1%), incontinence procedures (-33.6%), and vasectomies (-22.8%), compared to the preceding year. Radical cystectomies and orchiectomies saw the lowest decrease, -5.9% and -8.6%, respectively. A similar trend was seen in the number of individuals newly diagnosed with urologic conditions and percentage of patients undergoing surgical intervention. The lowest drops were seen with ureteral stent placements (-5.0%) and prostate biopsies (-3.1%). CONCLUSIONS: The number of people receiving urologic diagnoses and surgical case load for urologic procedures significantly reduced during the first year of the COVID pandemic. Providers should be aware of this healthcare disparity, and greater efforts made to identify these missed patients moving forward.

COVID-19 VACCINATION IS ASSOCIATED WITH A DECREASED RISK OF ORCHITIS AND/OR EPIDIDYMITIS IN MEN

INTRODUCTION AND OBJECTIVE: Vaccine hesitancy is a major public health obstacle to fighting the ongoing COVID-19 epidemic. Due to studies that show COVID-19 infection can affect sperm parameters and lead to orchitis, the public are concerned about how the COVID vaccines may impact male reproduction. In this study, we investigated the association between COVID-19 vaccination and risk of developing orchitis and/or epididymitis outcomes in a cohort of men using a large, US-based, electronic health record database (TriNetX). METHODS: We queried the database for male patients ages 12 years and older who received a single-dose COVID-19 vaccine or at least 1 dose of a 2-dose regimen using specific ICD-10 medication and procedure codes and compared them to a cohort of men who had no record of any COVID-19 vaccination in their health record. The outcome for analysis was diagnosis of orchitis and/or epididymitis (ICD-10-CM: N45-N45.4, N51) between 1-9 months after the index event of COVID-19 vaccination. The two cohorts were balanced for the following potentially confounding variables through propensity score matching: age at index event, race, urinary tract infection, and unspecified sexually transmitted disease. We determined the association between COVID-19 vaccination and orchitis and/or epididymitis using logistic regression analysis with statistical significance assessed at p<0.05. RESULTS: We identified 663,774 men in the database who had received at least one dose of a COVID-19 vaccine, and 9,985,154 who did not. Prior to propensity score matching, 0.051% of men in the vaccinated cohort and 0.083% in the unvaccinated cohort received a diagnosis of orchitis and/or epididymitis in the time window (OR =0.619;95% CI: 0.556 - 0.690;p<0.0001). After balancing for potentially confounding variables, the COVID-19 vaccine remained protective against development of orchitis and/or epididymitis (OR =0.568;95% CI: 0.497 - 0.649;p<0.0001). CONCLUSIONS: In this retrospective cohort study, we demonstrated that receiving a COVID-19 vaccine is associated with a decreased risk of developing orchitis and/or epididymitis. These findings have important implications in the counseling of patients that are hesitant to receive the COVID-19 vaccine and refute misinformed claims on social media regarding the effect of the vaccines on male fertility.

CONCERNS ABOUT FERTILITY: A MAJOR CAUSE OF COVID-19 VACCINE HESITANCY IN THE UNITED STATES

INTRODUCTION AND OBJECTIVE: As of June 2021, three vaccines have been issued Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA) to combat SARS-CoV-2. However, vaccine hesitancy rates have remained steady with 10.2% of Americans stating they probably not get a vaccine, and 8.2% stating they would definitely not get a vaccine. Thus, we evaluated the current reasons for COVID-19 vaccine hesitancy among the unvaccinated U.S. population. METHODS Amazon Mechanical Turk (MTurk) was used to survey the unvaccinated U.S. adult population between June 30 - July 1, 2021. The survey was available to complete for individuals above the age of 18 located in the United States who never received any COVID-19 vaccine at any time. The anonymous 32-question survey focused on identifying perceptions toward COVID-19 vaccination and potential factors that may encourage uptake. Demographic information such as age, race/ethnicity, and relationship status were collected for analysis. RESULTS: A total of 914 adults responded to our survey with 53% of respondents identifying as cis-male and 42% as cis-female. When assessing reasons why individuals have elected against vaccination, we found that 58% are worried about unknown long term adverse effects (Figure 1A). Of these, 41% believed the 'COVID-19 vaccines can negatively impact reproductive health and or fertility, and 38% were unsure of the effects on fertility (Figure 1B). In addition, 48% of all unvaccinated respondents said additional information and research conducted on COVID-19 vaccines would encourage vaccination while only 11% of them claimed that financial incentives would encourage them. CONCLUSIONS: Using Amazon MTurk, we demonstrated that fertility concerns constitute a significant barrier to vaccine uptake among the unvaccinated U.S. population. In addition, we found that more information and research conducted on the COVID-19 vaccines would encourage vaccination among all unvaccinated respondent in addition to those fearful of fertility side effects. Such information may be of immense use to public health officials in promoting COVID-19 vaccine uptake and protecting the U.S. population amidst this global pandemic.

ULTRASTRUCTURAL FINDINGS OF COVID-19 INFECTION IN THE PROSTATE

INTRODUCTION AND OBJECTIVE: SARS-CoV-2 utilizes two integral membrane proteins ACE2 and TMPRSS2 for viral replication. It has been established TMPRS22 specifically is found in high concentrations throughout the prostate found to be linked to prostatic disease progression. This project examined the histopathological, ultrastructural, and immunofluorescent elements of prostatic tissue from men infected by SARS-CoV-2. METHODS: We evaluated prostate tissue in men with worsening lower urinary tract symptoms who underwent HoLEP procedure after SARS-CoV-2 infection. Biopsied tissue was visualized by transmission electron microscopy (TEM), immunofluorescence, and viral presence was confirmed by quantitative polymerase chain reaction (RT-PCR). RESULTS: Multiple coronavirus-like spiked viral particles ranging from 73.3mm to 109mm were visualized by TEM (Figure). Histochemical and immunofluorescence concurrently showed presence of distinct hyalinization, fibrosis, and presence of spike protein (Figure 2). RT-PCR confirmed the identity of the viral bodies as SARS-CoV-2 (Figure 3). CONCLUSIONS: This study provides evidence that SARSCoV- 2 not only enters prostatic tissue but may persist beyond initial infection period. In addition to establishing the persistence of SARSCoV- 2 particles in prostatic tissue, this report suggests the importance of discerning the relationships between COVID-19, lower urinary tract symptom severity, and prostatic hyperplasia. (Figure Presented).

WHOLE EXOME SEQUENCING IDENTIFIES A RARE NONSENSE MUTATION IN NACAD AS A POSSIBLE CAUSE OF COVID ORCHITIS IN BROTHERS

OBJECTIVE: This project sought to uncover genetic explanations as to why certain men face increased susceptibility to developing COVID orchitis. Our goal was to identify genetic variants associated with COVID orchitis in a group of patients, aided by whole-exome sequencing and protein phenotyping of affected patients. MATERIALS AND METHODS:We identified and examined six COVID- 19 patients who all were confirmed with polymerase chain reaction (PCR), including three COVID-19 (+) men without orchitis (controls) and three COVID (+) men with orchitis (bilateral testicular pain for at least 5 days around the time of testing PCR positive). Of note, among the three men with COVID-19 who had orchitis, two of them were siblings.DNA extraction and whole exome sequencing were performed on blood using the QIAmp blood maxi kit on five of the six patients. Variants were prioritized by being shared between the three patients affected with orchitis, absent in controls, and introducing nonsense, frameshift, splicing or non-synonymous amino acid changes and less than 10% in population prevalence. Based on WES findings, DuoSet® Human ACE2 reagent kit 2 (catalog number: DY933- 05) was purchased from R&D Systems, USA, and used to measure the level of soluble ACE2 in the plasma samples. RESULTS: The average age of the men in the study was 25 years old. The average duration of COVID symptoms (fever, sore throat, cough, body aches) were 7 days. Among the men who developed bilateral testis pain, the symptoms lasted for an average of 22 days. The median sperm concentration and sperm motility was 19 million/cc and 60% around 3 months after original infection. A list of 16 variants was generated that found to be shared between the two siblings with COVID orchitis along with the unrelated subject with COVID orchitis, and not present in the two controls. Among the 16 variants, a nonsynonymous non-frameshit deletion in NACAD variant on chromosome 7 with a frequency of 3.9% prevalence in ExAC was prioritized based on known involvement in the ACE2 pathway, read depth, and genotype quality. Phenotypically, we found that circulating levels of solubleACE2 was 3.72 ng/ml among men who had COVID orchitis and was lower than men who developed COVID without orchitis. CONCLUSIONS: We observed a stop mutation in NACAD in 2 brothers and 1 unrelated man who developed COVID orchitis. Interestingly, we found lower circulating ACE2 serum levels in both brothers with orchitis and the one nonrelated orchitis subject but normal serum levels in all controls. NACAD when involved with cellular ability to shuttle out ACE2 becomes critical for COVID symptomatology. With decreased transcellular and extracellular transport of ACE2 being possible in subjects with the gene mutation, it can be postulated more ACE2 will be found intracellularly leading to increased cellular entry of SARS CoV-2 and possibility of orchitis sequelae. IMPACT STATEMENT: These findings provide an explanation as to why genetic variations can lead to some patients developing comorbidities such as orchitis from COVID-19.

SARS-COV-2 ENDOTHELIAL DYSFUNCTION CAN CAUSE ERECTILE DYSFUNCTION: HISTOPATHOLOGICAL, IMMUNOHISTOCHEMICAL AND ULTRASTRUCTURAL STUDY OF THE HUMAN PENIS

OBJECTIVE: To describe the histopathological features of penile tissue of patients who recovered from symptomatic COVID-19 infection and subsequently developed severe erectile dysfunction (ED). MATERIALS AND METHODS: After providing informed consent, penile tissue was collected from patients undergoing surgery for inflatable penile prosthesis due to severe ED under an IRB approved protocol. Two specimens were obtained from men with a history of COVID-19 infection and two specimens were obtained from men with no history of infection (all men tested negative immediately before surgery). Tissue from COVID-19 (+) and COVID-19 (-) specimens were imaged with transmission electron microscopy (TEM). The tissue was analyzed for viral RNA using polymerase chain reaction (PCR) and viral spike protein. Formalin-fixed paraffinembedded tissues were stained with hematoxylin and eosin (H&E) and subjected to immunohistochemical analysis for endothelial Nitric Oxide Synthase (eNOS) expression (marker of endothelial function). Endothelial progenitor cells (EPC) function was assessed ex vivo by determination of endothelial colony forming units from blood samples collected from the COVID-19 (+) and COVID (-) men with severe ED. RESULTS: TEM revealed extracellular viral particles ∼100 nm in diameter, with prominent peplomers (spikes), and electron-dense dots of the nucleocapsid inside the particles near penile vascular endothelial cells of the COVID-19 (+) patients. Notably, viral particles were not detected in tissue obtained from COVID-19 (-) men. COVID-19 RNA was detected in both the penis biopsy samples from men with a history of COVID, but not in the samples from COVID-19 (-) men. There were no significant differences in H&E staining between COVID-19 (+) and COVID-19 (-) men and viral spike protein was not detected. Immunohistochemistry showed decreased eNOS expression in the corpus cavernosum of COVID-19 (+) men compared to COVID-19 (-) men, consistent with endothelial dysfunction. COVID-19 spike protein-positive cells could not be detected by immunofluorescence despite positive COVID-19 PCR. EPC levels from the COVID-19 (+) men were 0 cell/well and 1.167 cell/well respectively compared to mean EPCs from 34 COVID-19 (-) men with severe ED (4.04 cells/well), suggesting impaired endothelial function. CONCLUSIONS: Our study is the first to demonstrate the presence of COVID-19 virus in the penis long after the initial infection in humans. Our study also suggests that widespread endothelial cell dysfunction from COVID-19 infection can contribute to resultant erectile dysfunction. Future studies will evaluate novel molecular mechanisms of how COVID-19 infection leads to ED. IMPACT STATEMENT: COVID-19 can linger in the penis long after initial infection and can contribute to erectile dysfunction.

EFFECT OF COVID-19 mRNA VACCINES ON SPERM QUALITY

OBJECTIVE: Fertility related safety data was neither reported in the clinical trials nor evaluated in animal models prior to emergency use authorization (EUA) for two novel mRNA vaccines, BNT162b2 and mRNA-127.1,2 Despite excellent safety profiles for both vaccines, 44% of Americans are hesitant in receiving the vaccine. Although the specific reasons for COVID-19 vaccine hesitancy are unknown, concerns over fertility has previously decreased other vaccine uptake. As COVID-19 vaccination in the United States opens to children and adolescents, evaluating any potential impact of the vaccine on male reproduction is imperative for public reassurance. We hypothesized that since both vaccines only contain mRNA encoding the SARS-CoV-2 spike protein without biologic ability to replicate live virus, the vaccines would not decrease semen parameters. MATERIALS AND METHODS: We conducted a single-center prospective cohort study after IRB approval from the University of Miami (#20201451). Healthy men aged 18-50 scheduled for mRNA COVID-19 vaccination in Miami, Florida were recruited.Participants provided a semen sample after 2-7 days of abstinence, prior to receiving the first dose of either vaccine and about 72 days after the second dose. Specimens were self-collected into a wide-mouth sterile container and semen analysis (SA) performed by HCLD trained andrology clinicians examined semen volume, concentration, motility, and total motile sperm count (TMSC). RESULTS: 45 men provided a semen sample. Neither median sperm concentration nor total motile sperm count (TMSC) declined post vaccination (Figure 1). There was no clinically significant change in TMSC. Only 12 (26.6%) men had a marginal decrease in TMSC. In fact, the remaining 33 (73.3%) men demonstrated normal sperm parameters. Importantly, 8 (17%) men with oligospermia prior to vaccination did not experience a decrease in spermatogenesis. Only one subject had an abnormal TMSC (TMSC ≤ 9) after vaccination. CONCLUSIONS: After receiving the two doses of the vaccines, we did not observe a clinically significant sperm parameter decline within the cohort, suggesting the vaccines do not negatively impact male fertility potential. IMPACT STATEMENT: This is the first male fertility evaluation of the COVID-19 mRNA vaccines, in which we found that the vaccines do not negatively impact semen parameters. (Table Presented).

COVID-19 is Associated with New Onset Erectile Dysfunction: Insights From a Multinational Registry

As the COVID-19 pandemic has been ongoing since 2019, we are just beginning to see some of the short and long-term effects of infection. Vascular integrity is necessary for erectile function, and endothelial damage associated with COVID-19 is likely to affect the penile vasculature. Recent studies have showed evidence of COVID-19 virus within penile tissue through electron microscopy. We hypothesized that the COVID-19 infection may be a contributing factor to subsequent development of erectile dysfunction (ED). To determine if men with recent COVID-19 infection was associated with subsequent increased risk for development of erectile dysfunction. We assessed the risk of ED in men with COVID-19 in the United States (US) using the TriNetX Research Network, a federated EMR network of over 42 healthcare organizations and 66 million patients from the US, from 2009-2020. We identified adult men (≥18 years) with a recorded COVID-19 infection (ICD-10-CM B34.2, U07.1, U07.2, J12.81, J12.82, B97.29) since January 1, 2020 and compared them to an equivalent number of adult men who had COVID-19. Men with prior history or diagnosis of ED were excluded. We accounted for confounding variables through propensity score matching for age, race, body mass index (BMI), and history of the following comorbid medical conditions: diabetes mellitus (ICD-10-CM E11), hypertension (ICD-10-CM I10), or hyperlipidemia (ICD-10-CM E78). We assessed the association between COVID-19 and ED (ICD-10-CM N52) as a primary outcome through regression analysis with statistical significance assessed at p<.05. Prior to propensity score matching, men with COVID-19 had an average age of 47.1 + 21.4 years, 13% had diabetes mellitus, and 27% had hypertension, while in men without COVID-19, average age was 42.4 + 24.3 years, 7% had diabetes, and 22% had hypertension. After propensity score matching, we compared 230, 517 men with COVID-19 to 232,645 men without COVID-19 and found that COVID-19 diagnosis was significantly associated with ED (OR 1.120, 95% CI 1.004-1.248, p=0.0416). Strengths include large sample size and adjustment for confounding variables. Limitations include lack of data regarding ED (mild vs moderate vs severe) or COVID-19 infection severity. Our study showed that there is an increased risk of developing ED post-COVID infection, suggesting possible long-term effects due underlying endothelial dysfunction. The exact mechanism of how COVID-19 virus leads to erectile dysfunction remains to be elucidated. No [ FROM AUTHOR] Copyright of Journal of Sexual Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Concerns About Fertility Found to Be Major Cause Of COVID-19 Vaccine Hesitancy in the United States

As of July 2021, three vaccines have been issued Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA) to combat SARS-CoV-2 with over 65% of U.S. adults having received at least one vaccine dose. However, up to 35% of the population are hesitant or refuse to get vaccinated. As reproductive toxicity studies were not conducted prior to EUA, adults have expressed concern about potential adverse effects of the vaccines on fertility and reproductive health. We evaluated the current reasons for COVID-19 vaccine hesitancy among the unvaccinated U.S. population and identified their demographic characteristics. Amazon Mechanical Turk (MTurk) was used to survey the vaccine hesitancy reasons amongst unvaccinated U.S. adult population between June 30, 2021-July 1, 2021. The project title listed for survey participants during distribution was "Covid-19 Vaccine Hesitancy Survey". The study was reviewed by the Institutional Review Board, and it was deemed an exemption. Users with addresses in the U.S., over the age of 18, and received no doses of any coronavirus vaccine at any time were invited to complete an anonymous 32-question survey with an estimated completion time of less than 10 minutes. The first part of the survey focused on identifying attitudes toward the COVID-19 vaccines while the latter queried demographic information such as age, race/ethnicity, and relationship status. Quantitative data was analyzed using by two-sample Z-test on Microsoft Excel (version 16.44) and MATLAB (version R2021a). A total of 914 unvaccinated adults completed our survey (response rate 91.4%) with 53% of respondents identifying as cis-male and 42% as cis-female. Of the participants, 58% indicated 'COVID-19 vaccine side effects or other potential unknown long-term effects' as their reason for remaining unvaccinated and 39% of them believed that 'COVID-19 vaccines can negatively impact reproductive health and/or fertility'. Among those participants that were concerned that COVID-19 vaccines could impact fertility, 42% (p = 0.010) lived in urban settings, 46% (p > 0.001) were married, and 38% (p = 0.020) of individuals were born outside of the U.S. About 1/2 of the participants stated that more information and research conducted on the COVID-19 vaccines would encourage them to get vaccinated. A large portion of the U.S. population remain fearful of the potential side effects associated with the coronavirus vaccines and more specifically negative impacts to their future reproductive health. These results objectively evidence that fertility concerns are significantly contributing to vaccine hesitancy and may continue to be a barrier for years to come if no interventions are made. With almost half of the participants yearning for more information and research this highlights the need for intense investigation and publicly available data on the effect of coronavirus vaccines on fertility. No [ FROM AUTHOR] Copyright of Journal of Sexual Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)