Monocyte-driven atypical cytokine storm and aberrant neutrophil activation as key mediators of COVID-19 disease severity.

Epidemiological and clinical reports indicate that SARS-CoV-2 virulence hinges upon the triggering of an aberrant host immune response, more so than on direct virus-induced cellular damage. To elucidate the immunopathology underlying COVID-19 severity, we perform cytokine and multiplex immune profiling in COVID-19 patients. We show that hypercytokinemia in COVID-19 differs from the interferon-gamma-driven cytokine storm in macrophage activation syndrome, and is more pronounced in critical versus mild-moderate COVID-19. Systems modelling of cytokine levels paired with deep-immune profiling shows that classical monocytes drive this hyper-inflammatory phenotype and that a reduction in T-lymphocytes correlates with disease severity, with CD8+ cells being disproportionately affected. Antigen presenting machinery expression is also reduced in critical disease. Furthermore, we report that neutrophils contribute to disease severity and local tissue damage by amplification of hypercytokinemia and the formation of neutrophil extracellular traps. Together our findings suggest a myeloid-driven immunopathology, in which hyperactivated neutrophils and an ineffective adaptive immune system act as mediators of COVID-19 disease severity.

High dimensional profiling identifies specific immune types along the recovery trajectories of critically ill COVID19 patients.

The COVID-19 pandemic poses a major burden on healthcare and economic systems across the globe. Even though a majority of the population develops only minor symptoms upon SARS-CoV-2 infection, a significant number are hospitalized at intensive care units (ICU) requiring critical care. While insights into the early stages of the disease are rapidly expanding, the dynamic immunological processes occurring in critically ill patients throughout their recovery at ICU are far less understood. Here, we have analysed whole blood samples serially collected from 40 surviving COVID-19 patients throughout their recovery in ICU using high-dimensional cytometry by time-of-flight (CyTOF) and cytokine multiplexing. Based on the neutrophil-to-lymphocyte ratio (NLR), we defined four sequential immunotypes during recovery that correlated to various clinical parameters, including the level of respiratory support at concomitant sampling times. We identified classical monocytes as the first immune cell type to recover by restoration of HLA-DR-positivity and the reduction of immunosuppressive CD163 + monocytes, followed by the recovery of CD8 + and CD4 + T cell and non-classical monocyte populations. The identified immunotypes also correlated to aberrant cytokine and acute-phase reactant levels. Finally, integrative analysis of cytokines and immune cell profiles showed a shift from an initially dysregulated immune response to a more coordinated immunogenic interplay, highlighting the importance of longitudinal sampling to understand the pathophysiology underlying recovery from severe COVID-19.

Hyponatremia associates with poor outcome in metastatic renal cell carcinoma patients treated with everolimus: prognostic impact.

BACKGROUND: The prognostication of metastatic renal cell carcinoma (mRCC) is based on Memorial Sloan Kettering Cancer Center (MSKCC) and International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk classifications. Research has shown that hyponatremia is associated with worse prognosis in cancer. We analyzed the association of hyponatremia and outcome in everolimus-treated mRCC patients. PATIENTS AND METHODS: Baseline and on-treatment (≤12 weeks) sodium in 233 mRCC patients was analyzed using Kaplan-Meier, Cox regression and logistic regression. Baseline sodium was correlated with baseline thrombocyte and neutrophil values. RESULTS: 65 (28%) and 41 (18%) patients had sodium < lower limit of normal (LLN) at baseline and on-treatment, respectively. Baseline sodium < LLN was associated with shorter overall survival (OS) (6.1 vs. 10.3 months; p < .001) and progression-free survival (PFS) (2.8 vs. 3.5 months; p = .04). On-treatment sodium < LLN was associated with shorter OS (5.4 vs. 9.9 months; p < .001) and PFS (2.8 vs. 4.0 months; p < .001). In multivariate analyses adjusted for IMDC factors, baseline and on-treatment sodium < LLN were significantly associated with shorter OS (adjusted HR 1.46 (95% CI 1.04-2.05); p = .02; adjusted HR 1.80 (95% CI 1.23-2.61); p = .002; respectively). On-treatment sodium < LLN was significantly associated with progressive disease (OR 0.23 (95% CI 0.10-0.56); p = .001). A landmark analysis demonstrated that on-treatment hyponatremia was significantly associated with shorter OS and PFS (p = .01 and p = .03, respectively). On-treatment normalization of hyponatremia was associated with improved OS (unadjusted HR 0.61 (95% CI 0.35-0.98); p = .04), as compared to patients with sustained hyponatremia throughout follow-up. CONCLUSIONS: Hyponatremia associates with poor outcome in mRCC patients treated with everolimus. On-treatment normalization of hyponatremia to normal sodium values associates with favorable outcome.

Everolimus-induced pneumonitis associates with favourable outcome in patients with metastatic renal cell carcinoma.

BACKGROUND: Mammalian target of rapamycin inhibitors may induce pneumonitis. We analysed the association of pneumonitis with outcomes in everolimus treated metastatic renal cell carcinoma (mRCC) patients. PATIENTS AND METHODS: Eighty-five mRCC patients received everolimus at Helsinki University Hospital (cohort A). Computed tomography (CT) verified pneumonitis was correlated with outcome using Kaplan-Meier, Cox regression and logistic regression. An independent cohort of 148 everolimus treated mRCC patients (cohort B) at Aarhus University Hospital was assessed for validation. RESULTS: In cohort A, CT-verified pneumonitis (N = 29, 34.1%) was associated with improved overall survival (OS) (24.7 versus 8.5 months; P < 0.001), progression-free survival (PFS) (5.5 versus 3.2 months; P = 0.002) and clinical benefit rate (CBR) 57.1% versus 24.1% (P = 0.003). In multivariate analyses pneumonitis was associated with improved OS (hazard ratio [HR], 0.22; 95% confidence interval [CI] 0.12-0.44; P < 0.001), PFS (HR 0.37; 95% CI 0.21-0.66; P = 0.001) and CBR (odds ratio [OR] 4.11; 95% CI 1.42-11.95; P = 0.01). In cohort B, CT-verified pneumonitis (N = 29, 19.6%) was associated with improved OS (12.9 versus 6.0 months; P = 0.02), PFS (6.0 versus 2.8 months; P = 0.02) and CBR (79.3% versus 39.5%; P < 0.001). In multivariate analyses pneumonitis was associated with improved OS (HR 0.58; 95% CI 0.36-0.94; P = 0.03), PFS (HR 0.61; 95% CI 0.39-0.95; P = 0.03) and CBR (OR 5.65; 95% CI 2.10-15.18; P = 0.001). In a combined multivariate analysis (N = 233), with pneumonitis as a time-dependent covariate, CT-verified pneumonitis was associated with longer OS (HR, 0.67; 95% CI 0.46-0.97; P = 0.03). Furthermore, in a landmark analysis, pneumonitis was associated with longer OS (17.4 versus 7.8 months; P = 0.01). CONCLUSIONS: Everolimus-induced pneumonitis is associated with improved outcome in patients with mRCC and may serve as a biomarker of everolimus efficacy.

Arthroscopic ultrasound technique for simultaneous quantitative assessment of articular cartilage and subchondral bone: an in vitro and in vivo feasibility study.

Traditional arthroscopic examination is subjective and poorly reproducible. Recently, we introduced an arthroscopic ultrasound method for quantitative diagnostics of cartilage lesions. Here we describe our investigation of the feasibility of ultrasound arthroscopy for simultaneous measurements of articular cartilage and subchondral bone. Human osteochondral samples (n = 13) were imaged using a clinical 9-MHz ultrasound system. Ultrasound reflection coefficients (R, IRC), the ultrasound roughness index (URI) and the apparent integrated backscattering coefficient (AIB) were determined for both tissues. Mechanical testing, histologic analyses and micro-scale computed tomography imaging were the reference methods. Ultrasound arthroscopies were conducted on two patients. The ultrasound reflection coefficient correlated with the Mankin score and Young's modulus of cartilage (|r| > 0.56, p < 0.05). Ultrasound parameters (R, IRC, AIB) for subchondral bone correlated with the bone surface/volume ratio (|r| > 0.70, p < 0.05) and trabecular thickness (|r| > 0.59, p < 0.05). Furthermore, R and subchondral bone mineral density were significantly correlated (|r| > 0.65, p < 0.05). Arthroscopic ultrasound examination provided diagnostically valuable information on cartilage and subchondral bone in vivo.

111In-labelled bleomycin complex for the differentiation of high- and low-grade gliomas.

The aim of this study was to evaluate 111In-labelled bleomycin complex (111In-BLMC) SPET in the differentiation of high- and low-grade gliomas. Nineteen glioma patients, 14 with high-grade and five with low-grade tumours, were studied 1, 4 and 24 h after the injection of 111In-BLMC. In the high-grade glioma group, there was significant uptake of 111In-BLMC in 12 patients and no uptake in two patients based on the visual classification of SPET images at 4 and 24 h. In the low-grade glioma group, one patient had low uptake at 4 and 24 h, but the other four patients showed no visible uptake. The mean tumour to extracerebral circulation activity ratio (T/Cr) at 4 h was 0.13 +/- 0.10 (n = 5) in low-grade gliomas and 1.7 +/- 1.0 (n = 14) in high-grade gliomas. At 24 h the T/Cr ratios were 0.56 +/- 0.21 and 3.4 +/- 1.7, respectively. The mean tumour to contralateral normal brain activity ratios (T/Br) were 5.0 +/- 3.9 (4 h) and 3.0 +/- 2.8 (24 h) in low-grade gliomas, and 37.2 +/- 37.3 (4 h) and 8.3 +/- 8.2 (24 h) in high-grade gliomas. These higher T/Br ratios did not, however, result in improved differentiation between the two groups of gliomas; at 4 h the T/Cr and T/Br ratios were of equal value, as two high-grade gliomas would have been misclassified as low-grade, but at 24 h the T/Br ratio resulted in more misclassifications. Our results show that 111In-BLMC can be used in the differentiation of high- and low-grade gliomas and that the selection of the reference area for calculating tumour to non-tumour ratios is important.

Control and intake of pesticide residues during 1981-1993 in Finland.

The use of pesticides has been monitored on the basis of sales statistics since 1953 in Finland and the information has been used for targeting the official food control to products where pesticides are mostly used. Food consumption and the earlier control results were also taken into account. The intake of pesticides has been estimated based on the control analysis and statistical food consumption data, where also the ratio of imports was taken into account. The samples were taken by food control authorities and analysed separately. In spite of slight bias owing to sampling for control purposes, the results are representative of the products consumed. The intake estimation method has been classified in the group Estimated Daily Intake (EDI). The intakes of a total of the 53 most commonly found pesticides were estimated. The intakes of the evaluated pesticides were below 2% of ADIs. The average daily intake was 75 micrograms per person in 1992 mainly from imported products, only 24% initiating from domestic products. The intake of pesticides from domestic vegetables, fruits and berries has been evaluated three times during 1977-1993. The daily intake of pesticide residues from these products has decreased from 16.9 micrograms to 3.7 micrograms. The intensive food control has decreased offences against the regulations. The method used seems to be suitable for the longterm monitoring. The average intake of pesticides is at a low level compared with the Acceptable Daily Intakes, thus further estimations by more defined methods are not necessarily needed. The advantage of the method adopted is that residue data can also be used to make more accurate Measured Daily Intake estimates for risk groups such as children and vegetarians.

Dietary intakes of nitrate, nitrite and NDMA in the Finnish Mobile Clinic Health Examination Survey.

Concern about potential health hazards of nitrate, nitrite and N-nitroso compounds necessitates calculations of exposures to these compounds and their distribution in normal populations. This study describes dietary intake of nitrate (NO3-), nitrite (NO2-) and N-nitrosodimethylamine (NDMA) among 5304 adult men and 4750 women, who participated in the Finnish Mobile Clinic Health Examination Survey in 1967-72. Food consumption data for each individual over the preceding year were collected by a dietary history interview. Intakes of nitrate, nitrite and NDMA from vegetables, fruits, cheese, meat and fish products were calculated using available values mainly derived from Finland and other countries in northern Europe. Nitrate and nitrite from drinking water were not included in the study. Mean daily dietary intake of nitrate was 77 mg, of nitrite 5.3 mg, and of NDMA 0.05 microgram respectively. Intake of NDMA from beer, estimated in a part of the study population, was 0.07 microgram per day. More than 90% of dietary nitrate was derived from vegetables, including potatoes. Nitrite was mainly provided by cured meat products. Cured meat products and smoked and salted fish were important food sources of NDMA. The total daily intake of nitrate was similar in men and women, whereas intakes of nitrite and NDMA were higher in men than in women. The diet of farmers was characterized by lower amounts of nitrate, nitrite and NDMA, whereas white collar workers and those employed in industry had higher intakes. Current smokers were exposed to higher dietary intakes of nitrate, nitrite and NDMA than non-smokers. Intakes of dietary nitrate, nitrite and NDMA estimated on an individual level are suggested to be useful in evaluating the health effects of these compounds in epidemiological studies.

Estimation of food additive intake. Nordic approach.

Food additive intake has been estimated in Finland by means of a stepwise system using simultaneously two different methods. The first method, based on food consumption and food control analysis, can be classified into the group of Estimated Daily Intake methods (EDI). The second method, a questionnaire to food manufacturers concerning the use of food additives, has been employed five times. Estimates have been timed to reflect legislative changes and their influence on the intake. The intake of most food additives and sweeteners by Finnish diabetic adolescents was well below Acceptable Daily Intakes (ADIs). The average nitrite intake, especially by children and adolescents, was greater. Estimates of nitrite intake by children varied between 39% and 89% of ADIs depending on the method used and the new ADIs given by the Joint FAO/WHO Expert Committee on Food Additives (JECFA). Diabetic children's and the mothers' daily intake of nitrite was shown to be greater when compared with that of non-diabetics and the results of that other Finnish study gives support the evidence that dietary nitrites may be associated with the development of Type I diabetes. New estimates of additive intakes, based on a nationwide control project carried out in 1994, will be worked out. The results will reflect the situation in Finland before EU membership.

Calculated dietary intakes of nitrate and nitrite by young Finns.

Dietary intakes of nitrate and nitrite of 1212 Finns aged 9, 12, 15, 18, 21, and 24 years were calculated using food consumption data obtained by the 48-hour recall method in 1986, in connection with the Study on Cardiovascular Risk in Young Finns. Files on nitrate and nitrite content of foods and water were compiled for this study. The mean daily intakes of nitrate (NO3-) and nitrite (NO2-) from food were 54.0 mg and 1.4 mg, respectively. Vegetables including potatoes contributed 86% of nitrate intake and meat products 69% of the nitrite intake. If two litres of water within the mode concentration class of nitrate and nitrite were used, the intake of nitrate from water would have been between 1.0 and 2.0 mg and the intake of nitrite between 0.0 and 0.2 mg.

Radioimmunotherapy with 90Y-labeled monoclonal antibodies in a nude mouse ovarian cancer model.

Tumor stroma contains much fibrin, and so monoclonal antifibrin antibody can accumulate in tumors. We treated nude mice bearing human ovarian carcinoma xenografts with 90Y-labeled monoclonal antifibrin antibody Fab fragments administered intratumorally. The survival time vs. a control group was significantly prolonged and tumor growth rate was decreased. Another group of animals was treated with 90Y-labeled OC 125-monoclonal antibody; these mice received the antibodies intratumorally, intraperitoneally or intravenously. The survival time was longest in the intratumorally treated group. There was no significant difference in survival between 90Y-labeled OC 125 and antifibrin in the intratumorally treated animal groups. The tissue activity distribution studies revealed that bone marrow is the critical organ. Intratumorally injected monoclonal 90Y-antifibrin antibodies were retained at least 36 h (up to 50% of injected activity per gram tumor tissue) in the xenograft after one treatment, causing cell death. Beta-camera imaging and immunohistochemistry were performed for studies of the correlation between 90Y activity and fibrin distribution in tumor specimens. These results were in concordance. In conclusion, intratumoral administration seems suitable for radioimmunotherapy, with an antibody that targets stromal structures. The accumulation can be successfully monitored by a beta-camera.

Plasma exchange therapy reduces the nursing care needed in Guillain-Barré syndrome.

The authors compared the effect of plasma exchange therapy on the need for nursing care for 26 patients with acute idiopathic Guillain-Barré syndrome. The patients were randomized either to a plasma exchange (PE) or conservative treatment group. The need for nursing care and the need for specialist nursing services was assessed daily by the nurses at the Department of Neurology. At first, the average need for care was the same for the two groups of patients, but the pattern of care over time was different, with the PE group needing more care at the beginning and then very much less care, whilst the conservative group needed a more uniform amount of care over the entire stay at hospital. In the PE group the need for specialist nursing services increased markedly, and the need for nursing care decreased rapidly after the first 2 weeks to a level lower than that needed by control group patients, probably because PE increased muscle forces of patients. This study suggests that PE treatment is useful in reducing patients' needs for nursing care, especially after the first 2 weeks following the treatment.

Nitrate, nitrite, and N-nitroso compounds in Finnish foods and the estimation of the dietary intakes.

An estimate of the dietary intakes of nitrite, nitrate and N-nitroso compounds is presented, based on the analytical data supplied by the Finnish Food Quality Control. Figures on the food consumption of the Finnish population, taken from a national dietary survey, and food consumption of 1768 children and adolescents over a 48-h recall period were used. The mean daily dietary nitrate intakes were estimated to be about 55 mg for the total population and for children and adolescents. The mean nitrite intakes were 1.88 mg for the total population and 1.07 mg for children and adolescents. The intake of N-nitroso compounds (NDMA) was estimated to be 0.08 micrograms for the total population and 0.02 micrograms for children. Nitrates were found to originate mainly from vegetables (80%), nitrites from meat products (97%) and nitrosamines mostly from fish products and beer. A comparison of the estimate of dietary intake of with ADI values indicated that the nitrite intake of the total population was 23% and by children 39% of ADI. The average weight was approximately 60 kg for adults and 20 kg for children. When measured average weight (39 kg) was used, and the nitrite intake was found to be 28% of ADI. Nitrate intakes from food additives were 2.5% and 1.4% of the ADI value, respectively. When the total nitrate intake from various food sources was compared with the ADI (which is given only for food additives), the estimated nitrate intake of the total population was 25% and that of children 28% of the ADI value.

Intake of saccharin and cyclamate from Finnish foods between 1979 and 1985.

The dietary intake of saccharin and cyclamate was investigated during the period 1979-1985 in order to find out about the use as sweeteners in the food industry and hospitals and to obtain intake data for the toxicological evaluation of sweeteners in the Finnish diet. Eighty-nine samples of desserts served in 85 hospitals were analysed in 1983. Other samples investigated were artificially sweetened commercial foods available in Finland, such as soft drinks, sweets and jellies. The intake evaluation was carried out with reference to the acceptable daily intake (ADI), with commercial portions for a child being 20 kg and for an adult 60 kg. The most important foods with regard to the intake of saccharin and cyclamate were soft drinks. In 1979, 1982 and 1985, soft drinks contributed 128%, 93%, and 51%, respectively, of the ADI of artificial sweeteners for children and 42%, 31%, and 17% for adults. Artificially sweetened desserts served in hospitals contributed to 35% of the ADI for children and 11% for adults.

Estimates on the intake of food additives in Finland.

An estimation of the intakes of 30 food additives in Finland was conducted combining analytical data, food balance sheets, import and export statistics. The results indicated that most calculated average food additive intakes were well below the ADI values and internationally at an acceptable level. The intakes of nitrates, nitrites, saccharin and cyclamates were above or close to the respective ADI values. More studies are planned on these substances in order to establish possible special risk groups.