SARS-CoV-2 infection activates inflammatory macrophages in vascular immune organoids (preprint)

SARS-CoV-2 provokes devastating tissue damage by cytokine release syndrome and leads to multi-organ failure. Modeling the process of immune cell activation and subsequent tissue damage is a significant task. Organoids from human tissues advanced our understanding of SARS-CoV-2 infection mechanisms though, they are missing crucial components: immune cells and endothelial cells. This study aims to generate organoids with these components. We established vascular immune organoids from human pluripotent stem cells and examined the effect of SARS-CoV-2 infection. We demonstrated that infections activated inflammatory macrophages. Notably, the upregulation of interferon signaling supports macrophages role in cytokine release syndrome. We propose vascular immune organoids are a useful platform to model and discover factors that ameliorate SARS-CoV-2-mediated cytokine release syndrome.

Restrained memory CD8+ T cell responses favors viral persistence and elevated IgG responses in patients with severe Long COVID. (preprint)

During the COVID-19 pandemic it was widely described that certain individuals infected by SARS-CoV-2 experience persistent disease signs and symptoms, Long COVID, which in some cases is very severe with life changing consequences. To maximize our chances of identifying the underpinnings of this illness, we have focused on 121 of the most severe cases from >1000 patients screened in specialized clinics in Sweden and Belgium. We restricted this study to subjects with objective measures of organ damage or dysfunction, >3 months following a verified, but mild-to-moderate SARS-CoV-2 infection. By performing systems-level immunological testing and comparisons to controls fully convalescent following a similar mild/moderate COVID-19 episode, we identify elevated serological responses to SARS-CoV-2 in severe Long COVID suggestive of chronic antigen stimulation. Persistent viral reservoirs have been proposed in Long COVID and using multiple orthogonal methods for detection of SARS-CoV-2 RNA and protein in plasma we identify a subset of patients with detectable antigens, but with minimal overlap across assays, and no correlation to symptoms or immune measurements. Elevated serologic responses to SARS-CoV-2 on the other hand were inversely correlated with clonally expanded memory CD8+ T cells, indicating that restrained clonal expansion enables viral persistence, chronic antigen exposure and elevated IgG responses, even if antigen-detection in blood is not universally possible.

Predictors of disease severity, clinical course, and therapeutic outcome in COVID-19 patients: Our experience with 1700 patients (preprint)

Objective: To investigate the impacts of demographic, hematological, and biochemical factors on the clinical course and the prognostic outcome in adult COVID-19 patients. Methods: This retrospective study was performed in the internal medicine departments of 2 hospitals and data were extracted from the medical files of 1700 adult COVID-19 patients (836 females, 49.2%; 864 males, 50.8%) with an average age of 48.23 ± 16.68 (range: 18-93). Clinical data included baseline descriptives, prior medical history, admission date, treatment, and hematological and biochemical blood test results. The relationship between the survival, length of hospitalization, hematological, and biochemical parameters was investigated. Results: Advanced age (p<0.001), presence of at least 1 comorbid disease (p=0.045), increased length of hospitalization (p=0.006), elevated white blood cell (p=0.001) and neutrophil (p=0.002) counts, increased serum levels of glucose (p=0.027), blood urea nitrogen (p<0.001), AST (p=0.006), LDH (p<0.001), CRP (p>0.001), and D-dimer (p=0.001). In contrast, diminution of serum levels of albumin (p<0.001), ALT (p=0.028), calcium (p=0.022), and platelet count (p=0.010) were associated with increased mortality. There was a positive and weak relationship between serum D-dimer levels and length of hospitalization. Conclusion: Our data imply that identification and validation of indicators that predict COVID-19 disease progression to improve health outcomes are crucial. Age, comorbidities, immunological response, radiographic abnormalities, laboratory markers, and signs of organ dysfunction may all predict poor outcomes individually or collectively. It is critical to identify characteristics that predict COVID-19 problems to guide clinical management, improve patient outcomes, and allocation of limited resources. Keywords: SARS-Cov-2, COVID-19; severity; prognosis; outcome

Demystifying COVID-19 Mortality Causes with Interpretable Data Mining (preprint)

While SARS-CoV-2 infection rates are declining, older adults remain vulnerable to severe disease with high mortality. Although there have been some studies on revealing different risk factors affecting the death of COVID-19 patients, such as bilirubin, organ failure, patient age, and underlying disease, they fail to provide a comprehensive analysis to reveal their relationships and interactive effects on the risk of death. Based on the demographic information, inspection indicators, and underlying diseases of 1917 patients (102 were dead) admitted to Xiangya Hospital over a 4-month period, we used the association rule mining method to identify the risk factors leading causes of death among elderly Omicron patients. Firstly, we used the Affinity Propagation clustering to extract key features such as blood parameters, liver function indicators, renal function indicators, coagulation function indicators, and underlying diseases affecting death from the dataset. Then, we applied the Apriori to obtain 7 groups of abnormal feature combinations with significant increments in mortality rate. The results showed a relationship between the number of abnormal feature combinations and mortality rates within different groups. For instance, patients with “C-reactive protein > 8 mg/L”, “neutrophils percentage > 75.0 %”, “lymphocytes percentage < 20 %”, and “albumin < 40 g/L” have a 2x mortality rate than the basic one. If the characteristics of “D-dimer > 0.5 mg/L” and “WBC > 9.5 * 10 9 /L” are continuously included in this foundation, the mortality rate can be increased to 3x or 4x. In addition, we also found that liver and kidney diseases significantly affect patient mortality. Given patients with liver and renal diseases associated with other abnormal features, their mortality rate can be as high as 100 %. These findings can support auxiliary diagnosis and treatment to, facilitate early intervention in patients, thereby reducing patient mortality.

Urinary cadmium concentration is associated with the severity and clinical outcomes of COVID-19: a bicenter observational cohort study (preprint)

Background Cadmium exposure can cause oxidative stress, induce inflammation, inhibit immune function, and therefore has significant impacts on the pathogenesis and severity of many diseases. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can also provoke oxidative stress and the dysregulation of inflammatory and immune responses. This study aimed to assess the potential associations of cadmium exposure with the severity and clinical outcomes of patients with coronavirus disease 2019 (COVID-19).Methods We performed a retrospective, observational, bicenter cohort analysis of patients with SARS-CoV-2 infection in Taiwan between June 2022 and July 2023. Cadmium concentrations in blood and urine were measured within 3 days of the diagnosis of acute SARS-CoV-2 infection, and the severity and clinical outcomes of patients with COVID-19 were analyzed.Results A total of 574 patients were analyzed and divided into a severe COVID-19 group (hospitalized patients) (n = 252; 43.9%), and non-severe COVID-19 group (n = 322; 56.1%). The overall in-hospital mortality rate was 11.8% (n = 68), and 149 patients (26%) required invasive mechanical ventilation. The severe COVID-19 patients were older, had significantly more comorbidities, and significantly higher neutrophil/lymphocyte ratio, C-reactive protein, and interleukin-6 than the non-severe COVID-19 patients (all p < 0.05). Both blood and urine cadmium concentrations were significantly higher in the severe COVID-19 patients than in the non-severe COVID-19 patients. Among the severe COVID-19 patients, those in higher urine cadmium/creatinine quartiles had a significantly higher risk of organ failure (i.e., higher APACHE II and SOFA scores), higher neutrophil/lymphocyte ratio, lower PaO2/FiO2 requiring higher invasive mechanical ventilation support, higher risk of acute respiratory distress syndrome, and higher 60-, 90-day, and all-cause hospital mortality (all p < 0.05). Multivariate logistic regression models revealed that urine cadmium/creatinine was independently associated with severe COVID-19 (adjusted OR 1.648 [95% CI 1.064–2.552], p = 0.025), and that a urine cadmium/creatinine value > 2.05 µg/g had the highest predictive value (adjusted OR 5.391, [95% CI 1.127–25.794], p = 0.035).Conclusions Urine cadmium concentration in the early course of COVID-19 could predict the severity and clinical outcomes of patients and was independently associated with the risk of severe COVID-19.

COVID-19 Caused by the Omicron Variant in Lung Transplant Recipients: A Single Center Case Series (preprint)

Background: Limited data from the Chinese experience are available regarding the infection status, clinical characteristics, treatments and early outcomes of lung transplant recipients (LTRs) afflicted with coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 Omicron Variant. Methods: We conducted a study on LTRs with COVID-19 caused by the Omicron Variant from November 17, 2022, to May 1, 2023. Clinical information was gathered through electronic medical records, questionnaires, or follow-up telephone calls. To identify potential risk factors for severe disease progression, a multivariate logistic analysis was performed. Results: 178 LTRs with COVID-19 were included, with 50% (89/178) requiring hospitalization for an average stay of 16 days (IQR: 9.5-25.5 days). The most common symptoms were fever (79.8%), dry cough (75.3%) and fatigue (61.8%). Ultimately, 17 recipients succumbed to COVID-19-related respiratory failure or secondary multiple organ dysfunction, resulting in an overall mortality rate of 9.6%. Of the 89 hospitalized patients, 41.6% (37/89) eventually progressed to severe or critical disease, forming the Severe/Critical Group (S/C group), while the remaining 58.4% (52/89) had mild to moderate disease (M/M group). In comparison to the M/M group, the S/C group had higher CRP (59.6 vs. 16.8 mg/L, P＜0.01), ESR (45.5 vs. 22.5mm/h, P＜0.01) and D-dimer (1.09 vs. 0.65 mg/L, P＜0.05), but lower CD3+ T lymphocytes (577 vs. 962 cells/ul, P＜0.01) and CD4+ T lymphocytes (217 vs. 427 cells/ul, P＜0.01). The S/C group had significantly higher rates of combined pulmonary bacterial infection (67.6% vs. 38.5%, P＜0.01) and pulmonary fungal infection (73.0% vs. 38.5%, P＜0.01) during the course of COVID-19, nearly double that of the M/M group. In a multivariate logistic analysis, elevated CRP (>41.8mg/L), combined pulmonary fungal infection, and interstitial lung disease(ILD) as primary disease emerged as high-risk factors for developing the severe disease phenotype following Omicron variant infection in LTRs, with respective OR values of 4.23 (95% CI: 1.68-11.23), 4.76 (95% CI: 1.59-15.64), and 5.13 (95% CI: 1.19-29.17). Conclusions: LTRs displayed an increased vulnerability to combined lung bacterial or fungal infections following Omicron infection. CRP> 41.8mg/L, ILD as primary disease, and combined pulmonary fungal infection are high-risk factors for developing severe disease.

Isolation and characterization of neutralizing monoclonal antibodies from a large panel of murine antibodies against RBD of the SARS-CoV-2 Spike protein (preprint)

Background Coronavirus disease 2019 (COVID-19) emerged in late December 2019 and was declared pandemic in March 2020 by the World Health Organization, causing clinically acute respiratory manifestations and corresponding symptoms, pathological inflammation and multi-organ dysfunctions. The total commitment of the scientific community to develop therapeutics to deal with this global emergency in the shortest possible period was unprecedented. In a very short time, several vaccines were approved by the EMA (European Medicines Agency) and the FDA (Food and Drug Administration). Despite this, it is conceivable that COVID-19 will continue to spread globally through evolving variants in more or less cyclic waves. With these perspectives, it is essential to quickly develop additional therapeutic tools to deal with the next wave of infection.  Methods In the present study we describe the development and characterization of neutralizing mouse monoclonal antibodies (mAbs) against the receptor binding domain (RBD) of the SARS-CoV-2 Spike (S) protein.  Results The mAbs identified are able to specifically detect the RBD of SARS-CoV-2 Spike protein in all tested applications, including enzyme-linked immunosorbent assay (ELISA), flow cytometry (FACS) and bio-layer interferometry. In addition, we show that these mAbs efficiently block entry of both SARS-CoV-2 pseudoparticles carrying the spike protein of the original SARS-CoV-2 strain and a broad set of variants of concern (VOC). Conclusions Here we report a panel of monoclonal antibodies that target RBD and inhibit SARS-CoV-2 variants  infection and enable the isolation of novel therapeutic tools to neutralize SARS-CoV-2 virus

Inclusion Criteria for Extracorporeal Membrane Oxygenation (ECMO) in Patients with Acute Respiratory Distress Syndrome (ARDS) Due to COVID-19: A Systematic Review (preprint)

IntroductionAt the end of 2019, in the city of Wuhan, China, a virus of the family of coronaviruses first appeared, mainly affecting the respiratory system, which was called SARS-COV-2 and causes COVID-19. Although in most patients, it occurs with mild symptomatology, however, a significant percentage (15-30%) will develop acute respiratory distress syndrome (ARDS) with increased chances of intubation and mechanical ventilation. In special cases of severe disease, where the oxygenation of the patient is not improved by the use of the ventilator, extracorporeal membrane oxygenation (ECMO) can be applied, a technique that has been used in previous pandemics that affected the respiratory system. AimTo investigate the evidence of the appliance of the ECMO, based on international literature, of the extracorporeal membrane oxygenator in patients with severe respiratory failure due to Covid-19 disease. MethodArticles were searched on the international bases of scientific studies PubMed, Cochrane Library, and Google Scholar. This review was carried out using meta-analysis and international guidelines. ResultsFour articles were included where there was an agreement on the basic characteristics of patients, which can be considered as selection criteria. The primary criteria indicate the age, where the patient must be under 65 years old, and the body mass index (BMI) should be below 40. In addition, it is very important that there is no serious underlying pathology such as multi-organ failure syndrome. Also, the mechanical ventilation should not exceed seven (7) days until the placement of the ECMO, while all the other therapeutic methods, such as the prone position, neuromuscular blockers, and the appropriate positive end-expiratory pressure of the airways (Positive end-expiratory pressure - PEEP) should be already applied. ConclusionsThe application of ECMO is widely used as a treatment for patients with severe COVID-19 disease. However, in order to have the best therapeutic results while reducing hospitalization costs, it is necessary to follow the guidelines regarding the selection of patients who will benefit substantially.

Predictive value of heparin-binding protein, interleukin-6, and C-reactive protein in severe COVID-19, organ failure, and prognosis: a retrospective study (preprint)

Background Systemic inflammation is closely related to the progress of COVID-19.This study aimed to explore the role of combined detection of heparin-binding protein (HBP), interleukin-6 (IL6), and C-reactive protein (CRP) on the severity and clinical outcomes of COVID-19. Methods Our hospital conducted a retrospective analysis of 214 patients with COVID-19 from 1 December 2022 to 28 February 2023. Patients were separated into non-severe and severe categories. Based on whether there was organ failure during hospitalization, patients were further split into the non-organ failure group and the organ failure group. Records on demographics, baseline, and clinical features, as well as the levels of HBP, IL6, and CRP on admission, were collected. Results HBP, IL6, and CRP levels were positively correlated with total bilirubin, lactate dehydrogenase, serum creatinine, and D-dimer but negatively correlated with albumin. HBP, IL6, and CRP levels were remarkably higher in severe, organ failure, and non-survivor groups compared to non-severe, non-organ failure, and survivor groups (all P < 0.001). The optimal cutoff values of HBP, IL6, and CRP for predicting severe COVID-19 were 49.71 ng/mL, 11.24 pg/mL, and 39.67 mg/L, respectively. With a sensitivity and specificity of 85.10% and 95.70% for severe COVID-19, the combined detection of HBP, IL6, and CRP showed the best diagnostic effectiveness. Logistic regression revealed that HBP, IL6, and CRP were independent risk factors for severe COVID-19 and organ failure. Moreover, the risk of death predicted by any two or more of HBP, IL6, and CRP higher than the optimal cutoff value was 3.631 times that of only one of the three indicators higher than the optimal cutoff value (hazard ratio = 3.631, log-rank P = 0.003). Conclusions A combination of HBP, IL6, and CRP has higher diagnostic efficiency of severe COVID-19; combined detection can more accurately and efficiently predict COVID-19 severity, organ failure, and prognosis, which is complementary to previous studies.

Unraveling antiviral efficacy of multifunctional immunomodulatory triterpenoids against SARS-COV-2 targeting virus-specific enzymes (preprint)

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) may be over, but its variants continue to emerge, and patients with mild symptoms having long COVID is still under investigation. SARS-CoV-2 infection leading to elevated cytokine levels and suppressed immune responses set off cytokine storm, fatal systemic inflammation, tissue damage, and multi-organ failure. Thus, drug molecules against virus-specific proteins that play a role in viral inflammation and simultaneous act on the host pathways participating in viral inflammation, will provide an effective antiviral therapy against emerging variants of concern. Evolutionarily conserved papain-like protease (PLpro) and main protease (Mpro) play an indispensable role in the virus life cycle and immune evasion. Direct-acting antivirals targeting both these viral proteases represent an attractive antiviral strategy that is also expected to reduce viral inflammation. The present study has evaluated the antiviral and anti-inflammatory potential of natural triterpenoids: azadirachtin, withanolide_A, and isoginkgetin. These molecules inhibit the Mpro and PLpro proteolytic activities with half-maximal inhibitory concentrations (IC50) values ranging from 1.42 to 32.7 M. Isothermal titration calorimetry (ITC) analysis validated the binding of these compounds to Mpro and PLpro. As expected, the two compounds, withanolide_A and azadirachtin exhibit potent antiviral activity with half-maximum effective concentration (EC50) values of 21.73 M and 31.19 M, respectively. The anti-inflammatory role of azadirachtin and withanolide_A when assessed using HEK293T cells were found to significantly reduce the levels of CXCL10, TNF, IL6, and IL8 cytokines, which are elevated in severe cases of COVID-19. Interestingly, azadirachtin and withanolide_A were also found to rescue the decreased type-I interferon response (IFN-1). The results of this study clearly highlight the role of triterpenoids as effective antiviral molecules that target SARS-CoV-2 specific enzymes and also host immune pathways involved in virus mediated inflammation.

SARS-CoV-2 variants of concern exhibit differential gastro-intestinal tropism and pathogenesis in the Syrian golden hamster model. (preprint)

The Coronavirus Disease 2019 (COVID-19) pandemic caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has taken its toll on worldwide public health infrastructure. SARS-CoV-2 is reported to exhibit wide tissue tropism, contributing to its severe pathogenicity that often culminates in multiple-organ failure. The onslaught of this disease has intensified due to the emergence of variants of concern (VOC), such as Delta and Omicron. These variants have been linked to gastrointestinal (GI) symptoms, suggesting a potential fecal-oral route of viral transmission. Here we compared the broad tissue tropism of ancestral Hong-Kong SARS-CoV-2 (SARS-CoV-2 HK) against Delta and Omicron VOCs in aa hamster model by analyzing tissue samples collected from the upper and lower respiratory system and the GI tract. We observed an overall increase in vRNA load and pro-inflammatory cytokines, especially in GI tracts of animals infected with Delta virus, indicating selective virus tropism and pathology in these tissues. However, no apparent spike in Delta viral load was observed in the large intestine and fecal matter. Overall, our research investigates the wide range of tissues that various SARS-CoV-2 strains can infect in hamsters and presents evidence supporting the increased preference of Delta VOCs for infecting the GI tract.

Randomized Clinical Trial of Antioxidant Therapy Patients with Septic Shock and Organ Dysfunction in the ICU: SOFA Score Reduction by Improvement of the Enzymatic and Non-Enzymatic Antioxidant System.

BACKGROUND AND AIM: Here, we assess the effect of adjuvant antioxidant therapies in septic shock patients with organ dysfunction and their effect on the enzymatic and non-enzymatic antioxidant systems. METHODS: Randomized clinical trial run between 2018 and 2022. One hundred and thirty-one patients with septic shock were included in five groups with 25, 27, 24, 26 and 29 patients each. Group 1 received vitamin C (Vit C), Group 2 vitamin E (Vit E), Group 3 n-acetylcysteine (NAC), Group 4 melatonin (MT) and group 5 no treatment. All antioxidants were administered orally or through a nasogastric tube for 5 days as an adjuvant to standard therapy. RESULTS: All patients had multiple organ failure (MOF) and low Vit C levels. Vit C therapy decreased CRP, PCT and NO3-/NO2- but increased Vit C levels. The SOFA score decreased with MT in 75%, Vit C 63% and NAC 50% vs. controls 33% (p = 0.0001, p = 0.03 and p = 0.001 respectively). MT diminished lipid peroxidation (LPO) (p = 0.01) and improved total antioxidant capacity (TAC) (p = 0.04). Vit E increased thiol levels (p = 0.02) and tended to decrease LPO (p = 0.06). Selenium levels were decreased in the control group (p = 0.04). CONCLUSIONS: Antioxidants used as an adjuvant therapy in the standard treatment of septic shock decrease MOF and oxidative stress markers. They increase the TAC and thiols, and maintain selenium levels.

Association of Molnupiravir and Nirmatrelvir-Ritonavir with reduced mortality and sepsis in hospitalized omicron patients: a territory-wide study.

This study evaluates the association between antivirals (Molnupiravir and Nirmatrelvir-Ritonavir) and all-cause and respiratory mortality and organ dysfunction among high-risk COVID-19 patients during an Omicron outbreak. Two cohorts, Nirmatrelvir-Ritonavir versus control and Molnupiravir versus control, were constructed with inverse probability treatment weighting to balance baseline characteristics. Cox proportional hazards models evaluated the association of their use with all-cause mortality, respiratory mortality, and all-cause sepsis (a composite of circulatory shock, respiratory failure, acute liver injury, coagulopathy, and acute liver impairment). Patients recruited were hospitalized and diagnosed with the COVID-19 Omicron variant between February 22, 2022 and April 15, 2022, and followed up until May 15, 2022. The study included 17,704 patients. There were 4.67 and 22.7 total mortalities per 1000 person-days in the Nirmatrelvir-Ritonavir and control groups respectively before adjustment (weighted incidence rate ratio, - 18.1 [95% CI - 23.0 to - 13.2]; hazard ratio, 0.18 [95% CI, 0.11-0.29]). There were 6.64 and 25.9 total mortalities per 1000 person-days in the Molnupiravir and control groups respectively before adjustment (weighted incidence rate ratio per 1000 person-days, - 19.3 [95% CI - 22.6 to - 15.9]; hazard ratio, 0.23 [95% CI 0.18-0.30]). In all-cause sepsis, there were 13.7 and 35.4 organ dysfunction events per 1000 person-days in the Nirmatrelvir-Ritonavir and control groups respectively before adjustment (weighted incidence rate ratio per 1000 person-days, - 21.7 [95% CI - 26.3 to - 17.1]; hazard ratio, 0.44 [95% CI 0.38-0.52]). There were 23.7 and 40.8 organ dysfunction events in the Molnupiravir and control groups respectively before adjustment (weighted incidence ratio per 1000 person-days, - 17.1 [95% CI, - 20.6 to - 13.6]; hazard ratio, 0.63 [95% CI 0.58-0.69]). Among COVID-19 hospitalized patients, use of either Nirmatrelvir-Ritonavir or Molnupiravir compared with no antiviral use was associated with a significantly lower incidence of 28-days all-cause and respiratory mortality and sepsis.

Fulminant onset COVID-19: predictors and outcome.

PURPOSE: During COVID-19 infection, organ dysfunction such as respiratory failure tends to occur towards the second week of illness; however, in a subset, there may be rapid onset of organ dysfunction as early as symptom onset. We define fulminant onset COVID-19 as rapid onset of organ dysfunction such as acute respiratory failure, acute kidney injury, acute encephalopathy or shock within 4 days of symptom onset. Fulminant onset COVID-19 has not yet been systematically studied. We aimed to identify predictors and prognosis of fulminant onset COVID-19. METHODS: This retrospective study was carried out on patients admitted to a single referral hospital in South India between June 2020 and January 2022. Patients were categorised into fulminant and non-fulminant onset COVID-19. Candidate predictors for fulminant onset were chosen by an intuitive approach and analysed using logistic regression. Then, the outcome of fulminant onset COVID-19 at 30 days was studied. RESULTS: Out of 2016 patients with confirmed COVID-19, 653 (32.4%) had fulminant onset COVID-19. Age>60 years (a-OR 1.57, 95% CI 1.30 to 1.90, p<0.001), hypertension (a-OR 1.29, 95% CI 1.03 to 1.61, p=0.03) and immune-suppressed state (a-OR 5.62, 95% CI 1.7 to 18.7, p=0.005) were significant predictors of fulminant onset COVID-19. Complete vaccination lowered the odds of fulminant onset COVID-19 significantly (a-OR 0.61, 95% CI 0.43 to 0.85, p=0.004). At 30 days, the fulminant onset COVID-19 group had higher odds of mortality and need for organ support. CONCLUSION: Fulminant onset COVID-19 is not uncommon and it carries poor prognosis and deserves recognition as a distinct phenotype of COVID-19.

[Application of immunosuppressive agents in crtical coronavirus disease].

The outbreak of novel coronavirus (SARS-CoV-2) infection has brought great harm to people's life and social development. Although SARS-CoV-2 infection is more common in mild patients at present, considering the characteristics of crtical disease, rapid progress and high mortality, the treatment of critical patients are the focus of clinical attention. Immune imbalance which is characterized by cytokine storm plays a vital role in SARS-CoV-2 induced acute respiratory distress syndrome (ARDS), extrapulmonary multiple organ failure and even death. Therefore, the application of immunosuppressive agent in crtical coronavirus disease patients has a promising prospect. In this paper, different immunosuppressive agents and their application in crtical SARS-CoV-2 infection are reviewed, so as to provide reference for crtical coronavirus disease therapy.

Acute Respiratory Distress Syndrome in Patients with COVID-19 vs Non-COVID-19: Clinical characteristics and outcomes in a tertiary care setting in Mexico City. (preprint)

Background ARDS due to COVID-19 infection has a unique phenotype generating a growing need to determine the existing differences that can alter existing evidence-based management strategies for ARDS, particularly those related to ventilator management.Research Question: What differences does the clinical profile of patients with ARDS due to COVID 19 and Non-COVID 19 have?Study Design and Methods: We conducted a comparative, observational, retrospective study in the ICU of a third-level hospital in Mexico City, from March 2020 through March 2022. Clinical, echocardiographic, and laboratory variables were compared between patients with ARDS due to SARS-COV2 infection and those due to other etiologies. For qualitative variables, the chi-square test was used.Results We enrolled 140 patients with a diagnosis of ARDS. The study group of COVID-19 etiology were younger males, higher body mass index, progressed to organ dysfunction, required more frequently renal replacement therapy, and higher SOFA score. There was no difference in rates of right ventricular dysfunction.Interpretation: COVID-19 ARDS exhibit much greater severity that led to higher admission and mortality rates, whilst being younger and less comorbid.

Researching COVID to enhance recovery (RECOVER) autopsy study protocol: Rationale, objectives, and design (preprint)

Importance: SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or organ dysfunction after the acute phase of infection, termed Post-Acute Sequelae of SARS-CoV-2 (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are poorly understood. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Tissue Pathology Study (RECOVER-Pathology) are to: (1) characterize prevalence and types of organ injury/disease and pathology occurring with PASC; (2) characterize the association of pathologic findings with clinical and other characteristics; (3) define the pathophysiology and mechanisms of PASC, and possible mediation via viral persistence; and (4) establish a post-mortem tissue biobank and post-mortem brain imaging biorepository. Methods: RECOVER-Pathology is a cross-sectional study of decedents dying at least 15 days following initial SARS-CoV-2 infection. Eligible decedents must meet WHO criteria for suspected, probable, or confirmed infection and must be aged 18 years or more at the time of death. Enrollment occurs at 7 sites in four U.S. states and Washington, DC. Comprehensive autopsies are conducted according to a standardized protocol within 24 hours of death; tissue samples are sent to the PASC Biorepository for later analyses. Data on clinical history are collected from the medical records and/or next of kin. The primary study outcomes include an array of pathologic features organized by organ system. Casual inference methods will be employed to investigate associations between risk factors and pathologic outcomes. Discussion: RECOVER-Pathology is the largest autopsy study addressing PASC among US adults. Results of this study are intended to elucidate mechanisms of organ injury and disease and enhance our understanding of the pathophysiology of PASC.

Impact of COVID-19 in patients on active melanoma therapy and with history of melanoma.

INTRODUCTION: COVID-19 particularly impacted patients with co-morbid conditions, including cancer. Patients with melanoma have not been specifically studied in large numbers. Here, we sought to identify factors that associated with COVID-19 severity among patients with melanoma, particularly assessing outcomes of patients on active targeted or immune therapy. METHODS: Using the COVID-19 and Cancer Consortium (CCC19) registry, we identified 307 patients with melanoma diagnosed with COVID-19. We used multivariable models to assess demographic, cancer-related, and treatment-related factors associated with COVID-19 severity on a 6-level ordinal severity scale. We assessed whether treatment was associated with increased cardiac or pulmonary dysfunction among hospitalized patients and assessed mortality among patients with a history of melanoma compared with other cancer survivors. RESULTS: Of 307 patients, 52 received immunotherapy (17%), and 32 targeted therapy (10%) in the previous 3 months. Using multivariable analyses, these treatments were not associated with COVID-19 severity (immunotherapy OR 0.51, 95% CI 0.19 - 1.39; targeted therapy OR 1.89, 95% CI 0.64 - 5.55). Among hospitalized patients, no signals of increased cardiac or pulmonary organ dysfunction, as measured by troponin, brain natriuretic peptide, and oxygenation were noted. Patients with a history of melanoma had similar 90-day mortality compared with other cancer survivors (OR 1.21, 95% CI 0.62 - 2.35). CONCLUSIONS: Melanoma therapies did not appear to be associated with increased severity of COVID-19 or worsening organ dysfunction. Patients with history of melanoma had similar 90-day survival following COVID-19 compared with other cancer survivors.

[Clinical analysis of severe/critical 2019 novel coronavirus Omicron variant infection combined with atrial fibrillation].

OBJECTIVE: To investigate the clinical characteristics and prognosis of coronavirus disease 2019 (COVID-19) patients with Omicron variant combined with atrial fibrillation (AF). METHODS: From March 23, 2022 to May 15, 2022, 2 675 aged ≥ 50 years old COVID-19 patients with AF were admitted to Zhoupu Hospital, the designated hospital for COVID-19 in Shanghai. Patients were divided into mild symptoms group, normal group, and serious/critical group according to the symptoms. The clinical data, imaging examination and laboratory results and prognosis of the three group patients were compared. RESULTS: The median age of 2 675 COVID-19 patients was 69.0 (60.0, 81.0) years old, the incidence of AF was 5.05% (135/2 675), the age range of AF patients were from 55 to 101 years old, with a median age of 84.0 (74.0, 89.0), and the number of mild symptoms, normal, serious/critical patients were 68, 30, 37, respectively, including 9 of serious and 28 of critical patients. In the serious/critical patients, aged 55-75 years old accounted for 43.2%, the rate of 2019 novel coronavirus vaccination was 32.4%. The identified new-onset AF was the highest among the three groups, but the rate of persistent AF was the highest in the mild symptoms group (58.8%). The severe/critical group complicated with fever (29.7%), hepatic insufficiency (13.5%), renal insufficiency (46.0%), type 2 diabetes (46.0%), and heart failure were higher in NYHA classification [compared with the mild symptoms and normal group (score): 1.8±1.1 vs. 1.1±0.8, 1.2±0.7, respectively, all P < 0.05]. In term of laboratory examinations, C-reactive protein (CRP), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were significantly higher in serious/critical patients compared to the mild symptoms and normal groups [CRP (mg/L): 27.2 (6.0, 60.8) vs. 7.6 (3.1, 19.3), 12.8 (4.9, 26.3), ALT (U/L): 31.3±15.4 vs. 15.4±9.3, 19.3±11.7, AST (U/L): 78.0±21.7 vs. 34.7±15.6, 38.1±24.4, all P < 0.05]. The hemoglobin (Hb) and albumin (ALB) levels were significantly lower than those in the mild symptoms and normal groups [Hb (g/L): 105.3±22.5 vs. 125.8±25.4, 123.0±20.4, ALB (g/L): 33.7±6.0 vs. 39.0±5.5 and 39.6±13.1, all P < 0.05]. In addition, MB isoenzyme of creatine kinase (CK-MB) was significantly higher in the serious/critical group than that in the mild symptoms group [µg/L: 2.5 (1.5, 3.4) vs. 2.2 (1.2, 2.8), P < 0.05]. In terms of the treatment, the percentage of antiplatelet agents and low-molecular heparin ratio compared among the three groups were statistically significant, with the serious/critical group using the lowest percentage of antiplatelet agents (27.0%) and a higher percentage of low-molecular heparin usage than that in mild symptoms group [81.1% (30/37) vs. 51.5% (35/68), P < 0.05]. In terms of prognosis, the mortality of patients with AF was 18.5% (25/135), all of whom were critical ill, including 32.0% (8/25) with cerebral embolism, pulmonary embolism and cerebral hemorrhage. Among them, 40.0% (10/25) died of multiple organ failure (40.0% combined with gastrointestinal hemorrhage), 20.0% (5/25) died of heart failure, and 12.0% (3/25) died of respiratory failure; while there were no death cases recorded in the mild symptoms, normal group and 9 serious patients. CONCLUSIONS: The serious/critical patients infected with COVID-19 Omicron variant with AF, have a worse prognosis and high mortality. Multiple organ failure, heart failure, sudden cardiac death, respiratory failure and embolic disease are the major causes of death.

Lipid metabolism of plasma-derived small extracellular in COVID-19 convalescent patients (preprint)

The coronavirus disease 2019 (COVID-19), which affects multiple organs, is causing an unprecedented global public health crisis. Most COVID-19 patients recover gradually upon appropriate interventions. Viruses were reported to utilize the small extracellular vesicles (sEVs) to escape the attack from the host’s immune system. This study aimed to examine the lipid profile of plasma small extracellular vesicles of recovered COVID-19 patients (RCs). Plasma sEVs were separated from 83 RCs 3 months after discharge without underlying diseases, including 18 recovered asymptomatic patients (RAs), 32 recovered moderate patients (RMs), and 33 recovered severe and critical patients (RSs), and 19 healthy controls (HCs) by Total Exosome Isolation. Lipids were extracted from sEVs and then subjected to targeted liquid chromatography-mass spectrometry. Size, concentration, and distribution of plasma-derived sEVs from RAs, RMs, RSs, and HCs did not differ in RCs and HCs as validated by transmission electron microscopy, nanoparticle tracking analysis, and immunoblot analysis. Fifteen subclasses of 508 lipids were detected in plasma sEVs from HCs, RAs, RMs, and RSs, such as phosphatidylcholines (PCs) and diacylglycerols (DAGs), etc. Total lipid intensity displayed downregulation in RCs compared with HCs. The relative abundance of DAGs gradually dropped, whereas PCs, lysophosphatidylcholines, and sphingomyelins were higher in RCs relative to HCs, especially RSs. 88 lipids out of 241 were significantly different and a conspicuous increase in lipid profiles of RCs was revealed with disease status. The lipids alternations were found to be significantly correlated with the clinical indices in RCs and HCs, suggesting that the impact of COVID-19 on lipid metabolism lingered for a long time. The lipid abnormalities bore an intimate link with glycerophospholipid metabolism and glycosylphosphatidylinositol anchor biosynthesis. Furthermore, the lipidomic analysis showed that RCs were at higher risk of developing diabetes and sustaining hepatic impairment. The abnormality of immunomodulation in RCs might still exist. The study may offer new insights into the mechanism of organ dysfunction and help identify novel therapeutic targets in the RCs.