Clinical characteristics and outcomes of critically ill mechanically ventilated COVID-19 patients receiving interleukin-6 receptor antagonists and corticosteroid therapy: a preliminary report from a multinational registry.

BACKGROUND: Interleukin-6 receptor antagonists (IL-6RAs) and steroids are emerging immunomodulatory therapies for severe and critical coronavirus disease (COVID-19). In this preliminary report, we aim to describe the epidemiology, clinical characteristics, and outcomes of adult critically ill COVID-19 patients, requiring invasive mechanical ventilation (iMV), and receiving IL-6RA and steroids therapy over the last 11 months. MATERIALS AND METHODS: International, multicenter, cohort study derived from Viral Infection and Respiratory Illness University Study registry and conducted through Discovery Network, Society of Critical Care Medicine. Data were collected between March 01, 2020, and January 10, 2021. RESULTS: Of 860 patients who met eligibility criteria, 589 received steroids, 170 IL-6RAs, and 101 combinations. Patients who received IL-6RAs were younger (median age of 57.5 years vs. 61.1 and 61.8 years in the steroids and combination groups, respectively). The median C-reactive protein level was > 75 mg/L, indicating a hyperinflammatory phenotype. The median daily steroid dose was 7.5 mg dexamethasone or equivalent (interquartile range: 6-14 mg); 80.8% and 19.2% received low-dose and high-dose steroids, respectively. Of the patients who received IL-6RAs, the majority received one dose of tocilizumab and sarilumab (dose range of 600-800 mg for tocilizumab and 200-400 mg for sarilumab). Regarding the timing of administration, we observed that steroid and IL-6RA administration on day 0 of ICU admission was only 55.6% and 39.5%, respectively. By day 28, when compared with steroid use alone, IL-6RA use was associated with an adjusted incidence rate ratio (aIRR) of 1.12 (95% confidence interval [CI] 0.88, 1.4) for ventilator-free days, while combination therapy was associated with an aIRR of 0.83 (95% CI 0.6, 1.14). IL-6RA use was associated with an adjusted odds ratio (aOR) of 0.68 (95% CI 0.44, 1.07) for the 28-day mortality rate, while combination therapy was associated with an aOR of 1.07 (95% CI 0.67, 1.70). Liver dysfunction was higher in IL-6RA group (p = 0.04), while the bacteremia rate did not differ among groups. CONCLUSIONS: Discordance was observed between the registry utilization patterns (i.e., timing of steroids and IL-6RA administration) and new evidence from the recent randomized controlled trials and guideline recommendations. These data will help us to identify areas of improvement in prescribing patterns and enhance our understanding of IL-6RA safety with different steroid regimens. Further studies are needed to evaluate the drivers of hospital-level variation and their impact on clinical outcomes. Trial registration ClinicalTrials.gov: NCT04486521. Registered on July 2020.

Prognostic Value of Coronary Artery Calcification Identified by the Semi-quantitative Weston Method in the Emergency Room or Other Hospitalized Patients.

Background: Coronary artery calcification (CAC) may provide insight to the patients' coronary artery disease (CAD) risks and influence early intervention. With increasing use of non-gated CT scans in clinical practice, the visual coronary artery scoring system (Weston Method) could quickly provide clinicians with important information of CAC for patient triage and management. Methods: We retrospectively studied the available CT imaging data and estimated CAC burden using the Weston method in 493 emergency room or other hospitalized patients. The Weston scores were calculated by the sum of the score for each vessel including the left main, left anterior descending, left circumflex artery and right coronary artery (range 0-12). The primary endpoint was a composite of the major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and coronary revascularization. Results: During a median follow-up of 85 months, a total of 25 (5.1%) MACE were recorded and 57 (11.2%) patients died from any causes. Detectable CAC was most common (96%) in the left anterior descending coronary arteries. Multivariable analysis showed that CAC total scores were independent predictors for MACE and all-cause mortality. Receiver operating characteristic analysis showed that CAC total score ≥5 was the optimal cutoff value for predicting MACEs. Conclusions: In the emergency room and hospitalized patients, the semi-quantitation of CAC burden using the Weston score system was related to the long-term cardiovascular outcomes including mortality. Clinicians and radiologists should maximize the value of non-contrast chest CT images by reporting CAC details.

Healthcare disparities among anticoagulation therapies for severe COVID-19 patients in the multi-site VIRUS registry.

Here we analyze hospitalized andintensive care unit coronavirus disease 2019 (COVID-19) patient outcomes from the international VIRUS registry (https://clinicaltrials.gov/ct2/show/NCT04323787). We find that COVID-19 patients administered unfractionated heparin but not enoxaparin have a higher mortality-rate (390 of 1012 = 39%) compared to patients administered enoxaparin but not unfractionated heparin (270 of 1939 = 14%), presenting a risk ratio of 2.79 (95% confidence interval [CI]: [2.42, 3.16]; p = 4.45e-52). This difference persists even after balancing on a number of covariates including demographics, comorbidities, admission diagnoses, and method of oxygenation, with an increased mortality rate on discharge from the hospital of 37% (268 of 733) for unfractionated heparin versus 22% (154 of 711) for enoxaparin, presenting a risk ratio of 1.69 (95% CI: [1.42, 2.00]; p = 1.5e-8). In these balanced cohorts, a number of complications occurred at an elevated rate for patients administered unfractionated heparin compared to patients administered enoxaparin, including acute kidney injury, acute cardiac injury, septic shock, and anemia. Furthermore, a higher percentage of Black/African American COVID patients (414 of 1294 [32%]) were noted to receive unfractionated heparin compared to White/Caucasian COVID patients (671 of 2644 [25%]), risk ratio 1.26 (95% CI: [1.14, 1.40]; p = 7.5e-5). After balancing upon available clinical covariates, this difference in anticoagulant use remained statistically significant (311 of 1047 [30%] for Black/African American vs. 263 of 1047 [25%] for White/Caucasian, p = .02, risk ratio 1.18; 95% CI: [1.03, 1.36]). While retrospective studies cannot suggest any causality, these findings motivate the need for follow-up prospective research into the observed racial disparity in anticoagulant use and outcomes for severe COVID-19 patients.

A giant left atrial mass-Clinical treatment dilemma.

A 74-year-old female current 75 pack-year smoker presented with shortness of breath and mild hemoptysis. Chest computed tomography showed a large right upper lobe mass compressing the superior vena cava, invading the right pulmonary veins, and occupying the majority of the left atrium. Brain magnetic resonance imaging revealed a 13 mm right parietal lesion with surrounding edema consistent with metastasis. A 3D TEE showed a large mobile mass in the left atrium. Bronchoscopy confirmed that the tumor mass was consistent with a moderately to poorly differentiated squamous cell carcinoma. She underwent chemotherapy, radiation, and immune therapy. She was also started on warfarin for anticoagulation after the initial chemotherapy with resolution of the left atrial mass. We feel that the patient most likely had carcinogenic thrombus in the pulmonary veins and left atrium.

A robust, general automatic phase correction algorithm for high-resolution NMR data.

The trends towards rapid NMR data acquisition, automated NMR spectrum analysis, and data processing and analysis by more naïve users combine to place a higher burden on data processing software to automatically process these data. Downstream data analysis is compromised by poor processing, and the automated processing algorithms must therefore be robust and accurate. We describe a new algorithm for automatic phase correction of frequency-domain, high-resolution NMR spectra. We show this to be reliable for data derived from a wide variety of typical NMR usages. We therefore conclude that the method will have wide-spread applicability and a positive impact on automated spectral processing and analysis. Copyright © 2017 John Wiley & Sons, Ltd.

Improving the Performance of High-Precision qNMR Measurements by a Double Integration Procedure in Practical Cases.

Quantitative (1)H NMR (qNMR) is a widely applied technique for compound concentration and purity determinations. The NMR spectrum will display signals from all species in the sample, and this is generally a strength of the method. The key spectral determination is the full and accurate determination of one or more signal areas. Accurate peak integration can be an issue when unrelated peaks resonate in an important integral region. We describe a "hybrid" approach to signal integration that provides an accurate estimation of signal area, removing the component(s) that may arise from unrelated peaks. This is achieved by using the most accurate integration method for the region and removing unwanted contributions. The key to this performing well, and in almost all cases, is the use of areas from deconvolved peaks. We describe this process and show that it can be very successfully applied to cases where the highest precision is required and for more common cases of NMR-based quantitation.

Optimization and automation of quantitative NMR data extraction.

NMR is routinely used to quantitate chemical species. The necessary experimental procedures to acquire quantitative data are well-known, but relatively little attention has been applied to data processing and analysis. We describe here a robust expert system that can be used to automatically choose the best signals in a sample for overall concentration determination and determine analyte concentration using all accepted methods. The algorithm is based on the complete deconvolution of the spectrum which makes it tolerant of cases where signals are very close to one another and includes robust methods for the automatic classification of NMR resonances and molecule-to-spectrum multiplets assignments. With the functionality in place and optimized, it is then a relatively simple matter to apply the same workflow to data in a fully automatic way. The procedure is desirable for both its inherent performance and applicability to NMR data acquired for very large sample sets.

In silico prediction of acyl glucuronide reactivity.

Drugs and drug candidates containing a carboxylic acid moiety, including many widely used non-steroidal anti-inflammatory drugs (NSAIDs) are often metabolized to form acyl glucuronides (AGs). NSAIDs such as Ibuprofen are amongst the most widely used drugs on the market, whereas similar carboxylic acid drugs such as Suprofen have been withdrawn due to adverse events. Although the link between these AG metabolites and toxicity is not proven, there is circumstantial literature evidence to suggest that more reactive acyl glucuronides may, in some cases, present a greater risk of exhibiting toxic effects. We wished therefore to rank the reactivity of potential new carboxylate-containing drug candidates, and performed kinetic studies on synthetic acyl glucuronides to benchmark our key compounds. Driven by the desire to quickly rank the reactivity of compounds without the need for lengthy synthesis of the acyl glucuronide, a correlation was established between the degradation half-life of the acyl glucuronide and the half life for the hydrolysis of the more readily available methyl ester derivative. This finding enabled a considerable broadening of chemical property space to be investigated. The need for kinetic measurements was subsequently eliminated altogether by correlating the methyl ester hydrolysis half-life with the predicted (13)C NMR chemical shift of the carbonyl carbon together with readily available steric descriptors in a PLS model. This completely in silico prediction of acyl glucuronide reactivity is applicable within the earliest stages of drug design with low cost and acceptable accuracy to guide intelligent molecular design. This reactivity data will be useful alongside the more complex additional pharmacokinetic exposure and distribution data that is generated later in the drug discovery process for assessing the overall toxicological risk of acidic drugs.

Reaction kinetics studied using diffusion-ordered spectroscopy and multiway chemometrics.

Nuclear magnetic resonance (NMR) spectroscopy is frequently used in the monitoring of reaction kinetics, due to its nondestructive nature and to the wealth of chemical information that can be obtained. However, when spectra of different mixture components overlap, as is common, the information available is greatly reduced, sometimes to the point where the identification of individual chemical species is not possible. In such cases, the resolution of component spectra and their concentration timecourses can be greatly improved by recording DOSY (diffusion-ordered spectroscopy) data for each time point during the reaction. Adding this additional degree of freedom to the experimental data, allowing the signals of different species to be distinguished through their different rates of diffusion, makes the data trilinear and, therefore, susceptible to analysis by powerful multiway (here, more specifically multilinear) model-free decomposition methods such as PARAFAC (parallel factor analysis). This approach is shown to produce high quality data even for species with near-degenerate spectra. Another important limitation of NMR is its inherently low sensitivity. Here, we show that the combination of DOSY and PARAFAC is surprisingly robust with respect to input data with low signal-to-noise ratio. High quality component spectra and kinetic profiles are obtained from a data set in which the signal-to-noise ratios of the reaction components in the spectra for individual time points are below the detection level.

Diffusion NMR and trilinear analysis in the study of reaction kinetics.

Measurement of diffusion-weighted NMR spectra as a function of time allows the time-dependence of concentration and the isolated spectrum to be found for each component in a reaction, without prior assumptions about spectra, kinetics or diffusion behaviour, by data decomposition using the PARAFAC algorithm.

Optimising reaction performance in the pharmaceutical industry by monitoring with NMR.

Quality assurance and process understanding are assuming increasing importance in the production of Active Pharmaceutical Ingredients (APIs). NMR has the potential to report on physical processes, quantities, structures, and speciation as chemical reactions progress. Following the progression of chemical reactions by placing the sample in an NMR tube, one can perform a large number of useful studies that provide chemical and mechanistic insight. But this simple approach can have limitations, and we have therefore constructed an apparatus comprising a laboratory reactor coupled with an NMR flow cell. The reactor duplicates the exact reaction conditions that will apply with large-scale production. This reaction mixture is sampled and pumped to a high-resolution NMR flow cell where the spectrum is recorded through the course of the reaction. We demonstrate the utility of reaction monitoring using NMR both for simple cases where tubes can be used, and describe the design of the on-flow apparatus and highlight its utility with an example.

The staying power of pain. A comparison of torture survivors from Bosnia and Colombia and their rates of anxiety, depression and PTSD.

The article describes symptoms of anxiety, depression and PTSD among Bosnian (n=17) and Colombian (n=17) torture survivors served by the Florida Center for Survivors of Torture, a programme of Gulf Coast Jewish Family Services, Inc. Information from clients enrolled in the programme for six months or more was collated over a 14 month period in order to better prioritize and design services for the two distinct populations. On average, the Bosnians in this sample experienced torture approximately 14 years ago while the Colombians'experience was approximately six years ago. Types of torture experienced by clients are documented using HURIDOCS and the number of family and friends affected by extreme trauma are counted. Employment and education levels attained are also identified. Findings show that 100% of Bosnians are symptomatic for depression and over half possess symptoms of PTSD compared to 35% of Colombians for depression and 18% for PTSD, despite the differences in years since trauma occurred. High incidences of torture experienced by Bosnian clients and high numbers of family and friends affected support the high rates of symptoms. For the Colombian clients, high rates of employment and years of education, as well as earlier intervention, may contribute to their lower rates of symptoms. The two client groups are distinguished by the unique circumstances experienced by each, including punctuated wartime versus a prolonged insurgency, as well as the refugee versus asylum seeker experience. This exploratory project informs the torture treatment model while recognizing the importance of ethnic, political and cultural perspectives affecting the healing process.

Selective excitation of overlapping multiplets; the application of doubly selective and chemical shift filter experiments to complex NMR spectra.

Standard 1D TOCSY and NOE experiments have limitations where signals are severely overlapped. Here, two recently published selective excitation methods are evaluated, the first of which uses a chemical shift selective filter to select a single resonance based on its chemical shift, and the second of which is a doubly selective experiment comprising a 1D TOCSY preparation step and subsequent 1D NOE. We also demonstrate the improvement in spectral quality obtained by the use of the zero quantum filter, which is incorporated into both of these experiments. The application of these different methods of selectively exciting overlapped multiplets, to different types of samples is considered.

A program for the visualisation, extraction, and reporting of NMR data from plate chemistry samples.

We describe a program for the viewing, analysis, and reporting of 1D NMR spectra. The program provides an intuitive environment to display 1D NMR spectra, and assists with data reduction and reporting. It is particularly well suited for multiple NMR spectra derived from the recording of spectra of samples in microtitre plates, where it adopts a unique, effective, and user-friendly approach. This also allows for quick overviews of the underlying NMR data and offers an effective tool for quality control in parallel chemistry.

A new general-purpose fully automatic baseline-correction procedure for 1D and 2D NMR data.

A new procedure for automatic baseline correction of NMR data sets is presented. It is based on an improved automatic recognition of signal-free regions that uses a Continuous Wavelet transform derivative calculation, followed by a baseline modelling procedure based on the Whittaker smoother algorithm. The method has been proven to automatically flatten 1D and 2D NMR spectra with large baseline distortions arising from different sources, is tolerant to low signal-to-noise ratio spectra, and to signals of varying widths in a single spectrum. Even though this procedure has so far only been applied to NMR spectra, we believe it to also be applicable to other spectroscopies having relatively narrow peaks (e.g., mass spectrometry), and potentially to those with broad peaks (e.g., near infrared or ultraviolet).

Which hydroxy? Evidence for species differences in the regioselectivity of glucuronidation in rat, dog, and human in vitro systems and dog in vivo.

The glucuronidation of (1S,2R,3R,5R)-3-(hydroxymethyl)-5-[7-{[(1R,2S)-2-phenylcyclopropyl]amino}-5-(propylthio)-3H-[1,2,3]triazolo[4,5-d]pyrimidin-3-yl]cyclopentane-1,2-diol (AZ11939714) was studied in UDP-glucuronic acid (UDPGA)-supplemented hepatic microsomes from rat, dog, and human liver. The major biliary metabolite of this compound after intraduodenal administration to a beagle dog was also studied. The techniques of HPLC, HPLC-MS and HPLC-NMR were used to characterize the glucuronides. An analysis of the proton NMR chemical shift differences between parent and metabolites was sufficient to deduce the sites of glucuronidation, although these were confirmed by 2D ROESY experiments. In dog microsomes, AZ11939714 was O-glucuronidated exclusively at the 1-position of the cyclopentanediol. This glucuronide was also the major metabolite in dog bile. In human microsomes, AZ11939714 was O-glucuronidated almost exclusively at the 3-hydroxymethyl position. Rat microsomes produced a mixture of glucuronides at the 2-position of the cyclopentanediol (major) and at the 3-hydroxymethyl position (minor). A clear qualitative species difference in the glucuronidation of AZ11939714 has been demonstrated in vitro. This may have implications for the choice of laboratory species to study the pharmacokinetics and safety of this compound.

A comparison of capillary-scale LC-NMR with alternative techniques: spectroscopic and practical considerations.

Experimental and practical details for the use of capillary LC (CapLC)-NMR are reported. The capillary NMR probe has high sensitivity and excellent flow characteristics and we found CapLC-NMR to be best suited to samples that are truly mass limited. CapLC-NMR relies on good capillary-scale chromatography where highly concentrated peaks with a volume closely matched to the NMR flow cell are achievable. Provided that the loading capacity of the capillary column is not limiting, the combination of high sensitivity and high solvent suppression quality makes CapLC-NMR an excellent choice. For many real samples, however, the loading is limiting and we found the combination of LC-SPE-MS-NMR with a cryoprobe enables more material to be purified for NMR analysis, while retaining sensitivity.